Provider First Line Business Practice Location Address: 
1981 CAPITAL CIR NE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
TALLAHASSEE
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
32308-4421
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
850-431-4739
    Provider Business Practice Location Address Fax Number: 
850-431-6325
    Provider Enumeration Date: 
10/05/2012