Provider First Line Business Practice Location Address: 
608 HIGHWAY 76 WEST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CLAYTON
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
30525-0031
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
706-782-3042
    Provider Business Practice Location Address Fax Number: 
706-212-2895
    Provider Enumeration Date: 
02/06/2007