Provider First Line Business Practice Location Address: 
317 1ST ST E
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CONOVER
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
28613-1715
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
828-464-4491
    Provider Business Practice Location Address Fax Number: 
828-464-4495
    Provider Enumeration Date: 
08/27/2014