Provider First Line Business Practice Location Address: 
6000 JOE FRANK HARRIS PKWY NW
    Provider Second Line Business Practice Location Address: 
SUITE D
    Provider Business Practice Location Address City Name: 
ADAIRSVILLE
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
30103-2443
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
770-773-9201
    Provider Business Practice Location Address Fax Number: 
770-773-9219
    Provider Enumeration Date: 
01/14/2008