Provider First Line Business Practice Location Address: 
201 CALLE TETUAN # 8
    Provider Second Line Business Practice Location Address: 
OLD SAN JUAN
    Provider Business Practice Location Address City Name: 
SAN JUAN
    Provider Business Practice Location Address State Name: 
PR
    Provider Business Practice Location Address Postal Code: 
00901-1816
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
787-552-7676
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
05/21/2014