Provider First Line Business Practice Location Address: 
2015 US HIGHWAY 441 N
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
OKEECHOBEE
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
34972-1901
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
863-763-1951
    Provider Business Practice Location Address Fax Number: 
863-357-2991
    Provider Enumeration Date: 
10/03/2006