Provider First Line Business Practice Location Address:
147 TOWER ST
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:
33852-6836
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-465-9992
Provider Business Practice Location Address Fax Number:
863-465-9906
Provider Enumeration Date:
10/20/2011