Provider First Line Business Practice Location Address: 
29 WASHINGTON STREET
    Provider Second Line Business Practice Location Address: 
STE 601-602 ASHFORD MEDICAL CTR
    Provider Business Practice Location Address City Name: 
SAN JUAN
    Provider Business Practice Location Address State Name: 
PR
    Provider Business Practice Location Address Postal Code: 
00907
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
787-249-9560
    Provider Business Practice Location Address Fax Number: 
509-275-5604
    Provider Enumeration Date: 
12/04/2014