Provider First Line Business Practice Location Address:
149 PROVIDENCE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28207-1217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-384-1056
Provider Business Practice Location Address Fax Number:
704-384-1063
Provider Enumeration Date:
09/13/2005