Provider First Line Business Practice Location Address:
126 EAST BROAD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUMPKIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-838-0885
Provider Business Practice Location Address Fax Number:
229-838-0887
Provider Enumeration Date:
10/12/2005