Provider First Line Business Practice Location Address:
155 E INTERLAKE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE PLACID
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33852-9578
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-699-0111
Provider Business Practice Location Address Fax Number:
863-699-1046
Provider Enumeration Date:
02/19/2008