Provider First Line Business Practice Location Address: 
2310 13TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
COLUMBUS
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
31906-2068
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
706-653-2221
    Provider Business Practice Location Address Fax Number: 
706-653-2210
    Provider Enumeration Date: 
09/25/2006