Provider First Line Business Practice Location Address: 
5680 N ALLEN RD SE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MABLETON
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
30126-2634
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
404-734-2923
    Provider Business Practice Location Address Fax Number: 
888-659-3693
    Provider Enumeration Date: 
01/21/2018