Provider First Line Business Practice Location Address: 
60 MECHANICSVILLE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DAHLONEGA
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
30533-0840
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
706-867-2727
    Provider Business Practice Location Address Fax Number: 
706-867-2739
    Provider Enumeration Date: 
03/13/2013