Provider First Line Business Practice Location Address: 
7201 NW 12TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MIAMI
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
33126-1908
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
305-592-5566
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/20/2006