Provider First Line Business Practice Location Address: 
302 E SCREVEN ST STE A
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
QUITMAN
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
31643-2180
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
229-263-4061
    Provider Business Practice Location Address Fax Number: 
229-263-5950
    Provider Enumeration Date: 
05/29/2019