Provider First Line Business Practice Location Address: 
5959 HIGHWAY 53 E STE 100
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DAWSONVILLE
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
30534-6288
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
706-381-6125
    Provider Business Practice Location Address Fax Number: 
706-531-0075
    Provider Enumeration Date: 
02/28/2018