Provider First Line Business Practice Location Address:
200 SE 12TH 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:
33316-1816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-463-2404
Provider Business Practice Location Address Fax Number:
954-463-2307
Provider Enumeration Date:
10/05/2005