Provider First Line Business Practice Location Address:
636 PROSPECT RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEMBROKE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-522-2124
Provider Business Practice Location Address Fax Number:
910-521-9190
Provider Enumeration Date:
03/29/2007