Provider First Line Business Practice Location Address: 
37 S ELLIS ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CAMILLA
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
31730-1812
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
229-336-8377
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/10/2006