Provider First Line Business Practice Location Address:
1125 E LEONARD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHPORT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28461-8316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-454-4001
Provider Business Practice Location Address Fax Number:
910-454-0300
Provider Enumeration Date:
05/18/2007