Provider First Line Business Practice Location Address: 
901 BAKER HWY W
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DOUGLAS
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
31533-2141
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
912-720-8448
    Provider Business Practice Location Address Fax Number: 
912-720-8449
    Provider Enumeration Date: 
10/01/2024