Provider First Line Business Practice Location Address: 
107 FAHM ST
    Provider Second Line Business Practice Location Address: 
B
    Provider Business Practice Location Address City Name: 
SAVANNAH
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
31401-2391
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
912-651-2253
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/02/2014