Provider First Line Business Practice Location Address: 
412 NORTHSIDE DR E
    Provider Second Line Business Practice Location Address: 
SUITE 200
    Provider Business Practice Location Address City Name: 
STATESBORO
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
30458-4802
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
912-764-9684
    Provider Business Practice Location Address Fax Number: 
912-489-8676
    Provider Enumeration Date: 
11/20/2006