Provider First Line Business Practice Location Address:
204 US 27 S
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:
33852-7900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-699-6155
Provider Business Practice Location Address Fax Number:
863-465-9656
Provider Enumeration Date:
03/30/2007