Provider First Line Business Practice Location Address: 
10 GLENLAKE PKWY
    Provider Second Line Business Practice Location Address: 
SUITE 130
    Provider Business Practice Location Address City Name: 
SANDY SPRINGS
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
30328-3495
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
678-365-6988
    Provider Business Practice Location Address Fax Number: 
770-719-2796
    Provider Enumeration Date: 
12/31/2014