Provider First Line Business Practice Location Address:
2100 DR MARTIN LUTHER KING JR ST N
Provider Second Line Business Practice Location Address:
DIVINE DERMATOLOGY PLLC
Provider Business Practice Location Address City Name:
ST PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33704-3264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-528-0321
Provider Business Practice Location Address Fax Number:
727-498-6632
Provider Enumeration Date:
07/27/2006