Provider First Line Business Practice Location Address: 
1313 NE 125TH ST
    Provider Second Line Business Practice Location Address: 
SUITE 100
    Provider Business Practice Location Address City Name: 
NORTH MIAMI
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
33161-5975
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
305-891-9177
    Provider Business Practice Location Address Fax Number: 
305-428-2643
    Provider Enumeration Date: 
01/09/2012