Provider First Line Business Practice Location Address: 
6377 US 29 BUS
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
REIDSVILLE
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27320-8957
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
336-451-0571
    Provider Business Practice Location Address Fax Number: 
336-342-9887
    Provider Enumeration Date: 
10/14/2009