Provider First Line Business Practice Location Address: 
6030 HIGHWAY 85 STE 240
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
RIVERDALE
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
30274-1535
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
770-996-5737
    Provider Business Practice Location Address Fax Number: 
770-996-5916
    Provider Enumeration Date: 
03/10/2007