Provider First Line Business Practice Location Address:
1600 MAPLE ST
Provider Second Line Business Practice Location Address:
UNIVERSITY OF WEST GA
Provider Business Practice Location Address City Name:
CARROLLTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30118-4700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-839-6452
Provider Business Practice Location Address Fax Number:
678-839-0656
Provider Enumeration Date:
08/28/2006