Provider First Line Business Practice Location Address:
48 S OLD LANTERN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIMBERLAKE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27583-8455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-323-9892
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2006