Provider First Line Business Practice Location Address: 
4930 AUSTELL RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
AUSTELL
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
30106-2006
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
770-941-2645
    Provider Business Practice Location Address Fax Number: 
770-944-2966
    Provider Enumeration Date: 
03/22/2011