Provider First Line Business Practice Location Address: 
2250 OSPREY BLVD STE 101
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BARTOW
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
33830-4340
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
863-644-8459
    Provider Business Practice Location Address Fax Number: 
863-533-8215
    Provider Enumeration Date: 
07/18/2006