Provider First Line Business Practice Location Address: 
111 LAKE HOLLINGSWORTH DR
    Provider Second Line Business Practice Location Address: 
FLORIDA SOUTHERN COLLEGE
    Provider Business Practice Location Address City Name: 
LAKELAND
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
33801-5607
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
863-680-4262
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/26/2006