Provider First Line Business Practice Location Address: 
3225 CUMBERLAND BLVD SE STE 100
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ATLANTA
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
30339-6408
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
770-293-8080
    Provider Business Practice Location Address Fax Number: 
770-293-8115
    Provider Enumeration Date: 
08/11/2006