Provider First Line Business Practice Location Address: 
17432 SOUTH HIGHLAND AVE.
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ARLINGTON
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
39813-0486
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
229-725-3135
    Provider Business Practice Location Address Fax Number: 
229-725-4029
    Provider Enumeration Date: 
07/24/2006