Provider First Line Business Practice Location Address: 
18170 US HIGHWAY 441
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MOUNT DORA
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
32757-6709
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
352-383-8121
    Provider Business Practice Location Address Fax Number: 
352-383-8183
    Provider Enumeration Date: 
03/26/2007