Provider First Line Business Practice Location Address: 
243 JONES COVE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CLYDE
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
28721-9483
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
828-452-8811
    Provider Business Practice Location Address Fax Number: 
828-627-2406
    Provider Enumeration Date: 
12/07/2005