Provider First Line Business Practice Location Address:
3573 LACKEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUMBERTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28360-9048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-738-1587
Provider Business Practice Location Address Fax Number:
910-739-6698
Provider Enumeration Date:
12/28/2006