Provider First Line Business Practice Location Address:
12 CALLE VICTORIA
Provider Second Line Business Practice Location Address:
LEGACY MEDICAL CENTER SUITE 22
Provider Business Practice Location Address City Name:
HUMACAO
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00791-4283
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-266-9151
Provider Business Practice Location Address Fax Number:
787-266-9152
Provider Enumeration Date:
09/30/2011