Provider First Line Business Practice Location Address:
250 EAST FOURTH AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT DORA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32757-5536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-735-1400
Provider Business Practice Location Address Fax Number:
352-735-3300
Provider Enumeration Date:
09/22/2006