Provider First Line Business Practice Location Address: 
3615 S FLORIDA AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LAKELAND
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
33803-4876
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
863-940-2091
    Provider Business Practice Location Address Fax Number: 
863-940-4764
    Provider Enumeration Date: 
05/20/2013