Provider First Line Business Practice Location Address: 
1074 S FLORIDA AVE
    Provider Second Line Business Practice Location Address: 
SUITE 103B
    Provider Business Practice Location Address City Name: 
LAKELAND
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
33803-1102
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
863-397-3232
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/22/2014