Provider First Line Business Practice Location Address: 
200 5TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ATLANTIC BEACH
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
32233-5312
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
904-241-7278
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/30/2008