Provider First Line Business Practice Location Address: 
1315 DELAUNEY AVE
    Provider Second Line Business Practice Location Address: 
SUITE 100
    Provider Business Practice Location Address City Name: 
COLUMBUS
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
31901-2367
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
706-341-9221
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/12/2006