Provider First Line Business Practice Location Address: 
201 TURNER MCCALL BLVD NW
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ROME
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
30165-2545
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
706-802-1991
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/06/2006