Provider First Line Business Practice Location Address:
205 N WATER ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ELIZABETH CITY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27909-4417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-619-6229
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/26/2009