Provider First Line Business Practice Location Address:
5575 N CROATAN HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHERN SHORES
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27949-3996
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-715-4733
Provider Business Practice Location Address Fax Number:
252-715-4701
Provider Enumeration Date:
11/15/2006