Provider First Line Business Practice Location Address:
SOUTHWIRE FAMILY MEDICAL CTR
Provider Second Line Business Practice Location Address:
1128 SOUTHPARK STREET
Provider Business Practice Location Address City Name:
CARROLLTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30119-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-836-0870
Provider Business Practice Location Address Fax Number:
770-836-1837
Provider Enumeration Date:
07/27/2006