Provider First Line Business Practice Location Address:
2433 STATEROAD 60 EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE WALES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33898-5122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-676-2717
Provider Business Practice Location Address Fax Number:
863-676-3390
Provider Enumeration Date:
12/28/2006