Provider First Line Business Practice Location Address:
4222 JOHNSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33021-5306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-322-9986
Provider Business Practice Location Address Fax Number:
954-322-6839
Provider Enumeration Date:
12/28/2006