Provider First Line Business Practice Location Address: 
600 E 25TH ST
    Provider Second Line Business Practice Location Address: 
SUITE A B
    Provider Business Practice Location Address City Name: 
HIALEAH
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
33013-3801
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
305-836-6016
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/26/2007