Provider First Line Business Practice Location Address:
204 US HIGHWAY 27 NORTH
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:
33852-5655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-465-9500
Provider Business Practice Location Address Fax Number:
863-465-9542
Provider Enumeration Date:
02/28/2007