Provider First Line Business Practice Location Address:
586 US HIGHWAY 27 N
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:
33852-9508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-699-2182
Provider Business Practice Location Address Fax Number:
863-659-4176
Provider Enumeration Date:
01/01/2006