Provider First Line Business Practice Location Address: 
1408A HIGHWAY 83 N
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DEFUNIAK SPRINGS
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
32433-3817
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
850-892-5013
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/16/2011