Provider First Line Business Practice Location Address: 
4949 S CONGRESS AVE
    Provider Second Line Business Practice Location Address: 
STE B
    Provider Business Practice Location Address City Name: 
LAKE WORTH
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
33461-4731
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
561-969-1777
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/24/2007