Provider First Line Business Practice Location Address:
430 WESTERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28677-5730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-873-7612
Provider Business Practice Location Address Fax Number:
704-872-8037
Provider Enumeration Date:
07/24/2006