Provider First Line Business Practice Location Address: 
1344 AUGUSTA AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SAVANNAH
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
31415-2063
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
912-272-3011
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/18/2015