Provider First Line Business Practice Location Address: 
2966 AVENTURA BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
AVENTURA
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
33180-3103
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
305-931-8382
    Provider Business Practice Location Address Fax Number: 
305-931-0142
    Provider Enumeration Date: 
08/08/2006