Provider First Line Business Practice Location Address: 
31922 US HIGHWAY 19 N
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PALM HARBOR
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
34684-3730
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
727-789-8812
    Provider Business Practice Location Address Fax Number: 
727-789-0653
    Provider Enumeration Date: 
01/03/2006