Provider First Line Business Practice Location Address:
224 E INTERLAKE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE PLACID
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33852-9603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-465-2751
Provider Business Practice Location Address Fax Number:
863-465-3977
Provider Enumeration Date:
07/16/2005