Provider First Line Business Practice Location Address:
150 MEDICAL BLVD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
STOCKBRIDGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30281-5053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-389-9944
Provider Business Practice Location Address Fax Number:
770-389-1973
Provider Enumeration Date:
08/10/2005