Provider First Line Business Practice Location Address: 
215 CHURCH ST STE 105
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DECATUR
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
30030-3330
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
404-626-9690
    Provider Business Practice Location Address Fax Number: 
770-808-9273
    Provider Enumeration Date: 
12/06/2012