Provider First Line Business Practice Location Address: 
2324 NE 53RD ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FT LAUDERDALE
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
33308-3212
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
954-990-6543
    Provider Business Practice Location Address Fax Number: 
954-491-4876
    Provider Enumeration Date: 
04/02/2007