Provider First Line Business Practice Location Address: 
4406 S FLORIDA AVE
    Provider Second Line Business Practice Location Address: 
SUITE 25
    Provider Business Practice Location Address City Name: 
LAKELAND
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
33813-2182
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
863-701-0109
    Provider Business Practice Location Address Fax Number: 
863-701-0309
    Provider Enumeration Date: 
02/13/2007