Provider First Line Business Practice Location Address: 
ORLANDO VA MEDICAL CENTER
    Provider Second Line Business Practice Location Address: 
5201 RAYMOND ST
    Provider Business Practice Location Address City Name: 
ORLANDO
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
32803
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
407-629-1599
    Provider Business Practice Location Address Fax Number: 
407-599-1571
    Provider Enumeration Date: 
05/23/2006