Provider First Line Business Practice Location Address: 
1450 N DRESSEL RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
AVON PARK
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
33825-6605
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
863-453-0145
    Provider Business Practice Location Address Fax Number: 
863-453-0145
    Provider Enumeration Date: 
11/20/2006