Provider First Line Business Practice Location Address: 
21780 SW 157 AVENUE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MIAMI-DADE
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
33170-2112
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
305-282-1975
    Provider Business Practice Location Address Fax Number: 
305-248-8235
    Provider Enumeration Date: 
02/12/2009