Provider First Line Business Practice Location Address: 
782 SW SISTERS WELCOME RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LAKE CITY
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
32025-0442
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
386-755-4518
    Provider Business Practice Location Address Fax Number: 
386-758-4500
    Provider Enumeration Date: 
01/10/2015