Provider First Line Business Practice Location Address: 
16934 S DIXIE HWY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
VILLAGE OF PALMETTO BAY
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
33157-4354
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
305-256-9910
    Provider Business Practice Location Address Fax Number: 
305-256-9910
    Provider Enumeration Date: 
12/22/2006