Provider First Line Business Practice Location Address:
1627 S LUMPKIN RD
Provider Second Line Business Practice Location Address:
SUITE 6
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31903-2719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-243-4154
Provider Business Practice Location Address Fax Number:
706-243-4154
Provider Enumeration Date:
11/16/2010