Provider First Line Business Practice Location Address:
3736 MIKE PADGETT HWY
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30906-0719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-560-2273
Provider Business Practice Location Address Fax Number:
706-560-0903
Provider Enumeration Date:
09/15/2008