Provider First Line Business Practice Location Address:
280 BROAD STREET
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
KERNERVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28284-2948
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-992-2672
Provider Business Practice Location Address Fax Number:
336-992-2674
Provider Enumeration Date:
07/18/2005