Provider First Line Business Practice Location Address: 
527 US HIGHWAY 27 S
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SEBRING
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
33870-2108
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
863-273-8747
    Provider Business Practice Location Address Fax Number: 
863-658-1328
    Provider Enumeration Date: 
08/31/2011