Provider First Line Business Practice Location Address: 
7901 4TH STREET N, STE 300
    Provider Second Line Business Practice Location Address: 
REGISTERED AGENTS INC FOR PHOENIX VIRTUAL TELEHEALTH
    Provider Business Practice Location Address City Name: 
ST PETERSBURG
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
33702
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
321-222-9287
    Provider Business Practice Location Address Fax Number: 
830-255-5842
    Provider Enumeration Date: 
05/23/2006