Provider First Line Business Practice Location Address:
1940 NE 47TH ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
FT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33308-7711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-772-4553
Provider Business Practice Location Address Fax Number:
954-771-2372
Provider Enumeration Date:
10/13/2005