Provider First Line Business Practice Location Address:
2872 YOUTH UNLIMITED DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOPHIA
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27350-8460
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-861-6380
Provider Business Practice Location Address Fax Number:
336-861-1417
Provider Enumeration Date:
07/21/2006