Provider First Line Business Practice Location Address:
5130 SOUTHPORT SUPPLY RD SE
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
SOUTHPORT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28461-9261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-269-4053
Provider Business Practice Location Address Fax Number:
910-363-4905
Provider Enumeration Date:
11/02/2005