Provider First Line Business Practice Location Address: 
3200 S UNIVERSITY DR
    Provider Second Line Business Practice Location Address: 
NSU THE EYE INSTITUTE SUITE 1402
    Provider Business Practice Location Address City Name: 
DAVIE
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
33328-2018
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
954-262-1402
    Provider Business Practice Location Address Fax Number: 
954-262-1818
    Provider Enumeration Date: 
11/20/2006