Provider First Line Business Practice Location Address:
1205 HIGHWAY 92 S
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30215-5434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-692-4815
Provider Business Practice Location Address Fax Number:
770-692-4814
Provider Enumeration Date:
12/16/2006