Provider First Line Business Practice Location Address: 
7015 N ARMENIA AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
TAMPA
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
33604-5252
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
813-443-5224
    Provider Business Practice Location Address Fax Number: 
813-443-5324
    Provider Enumeration Date: 
10/24/2011