Provider First Line Business Practice Location Address:
214 DOCTOR STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARTA
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28675-9247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-372-5606
Provider Business Practice Location Address Fax Number:
336-372-6211
Provider Enumeration Date:
11/30/2005