Provider First Line Business Practice Location Address: 
2512 UNIVERSITY DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
THOMSON
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
30824-0040
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
706-831-2140
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/28/2015