Provider First Line Business Practice Location Address:
113 N WEDGEWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27889-9231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-521-5256
Provider Business Practice Location Address Fax Number:
919-249-5606
Provider Enumeration Date:
10/30/2025