Provider First Line Business Practice Location Address: 
4050 HIGHWAY 142
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NEWBORN
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
30056-2007
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
706-714-8977
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/24/2007