Provider First Line Business Practice Location Address:
27 US 27 S
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:
33852-7916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-465-4904
Provider Business Practice Location Address Fax Number:
863-465-4650
Provider Enumeration Date:
11/14/2006