Provider First Line Business Practice Location Address: 
1616 RIGGINS RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
TALLAHASSEE
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
32308-5316
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
850-656-8911
    Provider Business Practice Location Address Fax Number: 
850-878-1824
    Provider Enumeration Date: 
07/18/2012