Provider First Line Business Practice Location Address: 
1430 HARPER STREET
    Provider Second Line Business Practice Location Address: 
BUILDING A
    Provider Business Practice Location Address City Name: 
AUGUSTA
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
30901
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
706-724-2261
    Provider Business Practice Location Address Fax Number: 
706-724-2523
    Provider Enumeration Date: 
04/02/2007