Provider First Line Business Practice Location Address:
1101 BROAD STREET EXT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORIENTAL
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28571-9790
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-249-2220
Provider Business Practice Location Address Fax Number:
252-249-2275
Provider Enumeration Date:
06/15/2006