Provider First Line Business Practice Location Address:
150 CLINIC AVENUE
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
CARROLLTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-834-0613
Provider Business Practice Location Address Fax Number:
770-836-5283
Provider Enumeration Date:
08/08/2006