Provider First Line Business Practice Location Address:
15830 BALLANTYNE MEDICAL PLACE
Provider Second Line Business Practice Location Address:
SUITE 175
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28277-3295
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-377-4009
Provider Business Practice Location Address Fax Number:
704-375-6970
Provider Enumeration Date:
08/22/2008