Provider First Line Business Practice Location Address: 
4633 NW 199TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
OPA LOCKA
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
33055-1508
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
305-625-6255
    Provider Business Practice Location Address Fax Number: 
305-628-2058
    Provider Enumeration Date: 
10/17/2006