Provider First Line Business Practice Location Address: 
10148 US HIGHWAY 19
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PORT RICHEY
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
34668-3743
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
727-869-9191
    Provider Business Practice Location Address Fax Number: 
727-869-9220
    Provider Enumeration Date: 
12/08/2005