Provider First Line Business Practice Location Address: 
OFIC. 563 EDIF. PRINCIPAL RCM
    Provider Second Line Business Practice Location Address: 
CENTRO MEDICO DE PUERTO RICO
    Provider Business Practice Location Address City Name: 
RIO PIEDRAS
    Provider Business Practice Location Address State Name: 
PR
    Provider Business Practice Location Address Postal Code: 
00935-0000
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
787-754-9165
    Provider Business Practice Location Address Fax Number: 
787-274-8156
    Provider Enumeration Date: 
07/19/2011