Provider First Line Business Practice Location Address:
242 KING AVE
Provider Second Line Business Practice Location Address:
MEDICAL SERVICES BUILDING, 2ND FLOOR
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30606-3506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-369-5474
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/24/2011