Provider First Line Business Practice Location Address: 
871 SW STATE ROAD 47
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LAKE CITY
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
32025-0433
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
386-755-1720
    Provider Business Practice Location Address Fax Number: 
386-754-1325
    Provider Enumeration Date: 
01/01/2015