Provider First Line Business Practice Location Address: 
285 SOUTH CENTRAL AVE.
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
UMATILLA
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
32784
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
352-669-3185
    Provider Business Practice Location Address Fax Number: 
352-669-1051
    Provider Enumeration Date: 
08/07/2006