Provider First Line Business Practice Location Address: 
CARR #2 KM 149.5
    Provider Second Line Business Practice Location Address: 
BO. SABANETAS
    Provider Business Practice Location Address City Name: 
MAYAGUEZ
    Provider Business Practice Location Address State Name: 
PR
    Provider Business Practice Location Address Postal Code: 
00680
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
787-832-5555
    Provider Business Practice Location Address Fax Number: 
787-832-5505
    Provider Enumeration Date: 
12/31/2014