Provider First Line Business Practice Location Address: 
1550 MALL OF GEORGIA BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BUFORD
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
30519-6551
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
678-288-3035
    Provider Business Practice Location Address Fax Number: 
678-288-3036
    Provider Enumeration Date: 
04/10/2015