Provider First Line Business Practice Location Address: 
2005 BARRINGTON LN
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
VILLA RICA
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
30180-6955
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
770-828-9600
    Provider Business Practice Location Address Fax Number: 
770-459-1358
    Provider Enumeration Date: 
10/09/2014