United Health Care

PO BOX 31362

SALT LAKE CITY UT 87726

114114363

Byrd Parthenia 04 23 1948 Byrd Parthenia

4715 S Florida Ave 4715 S Florida Ave

Lakeland FL Lakeland FL

33813 33813

04 23 1948

Signature on File Signature on File

0
E11.22 I10 I48.91 1

ZZ 207R00000X
06 02 23 06 02 23 02 99212 A 62.54 1 1710946553

DDC391791 62.54
888 850-5188
Dedicated Senior Medical Centers Lakeland South Dedicated Senior Medical Centers Lakeland South
4715 S Florida Ave 1395 NW 167th Street
Sabat Nancy MD Lakeland FL 33813 Miami Gardens FL 33169-5373
20230609
ZZ207R00000X

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