Provider First Line Business Practice Location Address:
1507 NORTH ROAD STREET
Provider Second Line Business Practice Location Address:
SUITE 1
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-338-6167
Provider Business Practice Location Address Fax Number:
252-334-1755
Provider Enumeration Date:
09/13/2006