Provider First Line Business Practice Location Address:
141 PIEDMONT AVENUE, SUITE D
Provider Second Line Business Practice Location Address:
GEORGIA STATE UNIVERSITY
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-413-1940
Provider Business Practice Location Address Fax Number:
404-413-1954
Provider Enumeration Date:
08/25/2008