Provider First Line Business Practice Location Address: 
18520 N DALE MABRY HWY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LUTZ
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
33548-7900
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
813-968-9411
    Provider Business Practice Location Address Fax Number: 
813-963-2407
    Provider Enumeration Date: 
08/10/2009