Provider First Line Business Practice Location Address: 
REAL PLAZA DEL SOL A
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ALGODONES
    Provider Business Practice Location Address State Name: 
BAJA CALIFORNIA
    Provider Business Practice Location Address Postal Code: 
21970
    Provider Business Practice Location Address Country Code: 
MX
    Provider Business Practice Location Address Telephone Number: 
011526861937551
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/25/2012