Provider First Line Business Practice Location Address: 
200 KNUTH RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BOYNTON BEACH
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
33436-4629
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
800-503-2143
    Provider Business Practice Location Address Fax Number: 
800-503-2055
    Provider Enumeration Date: 
01/10/2012