Provider First Line Business Practice Location Address:
404 S LEWIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TABOR CITY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28463-2316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-653-3242
Provider Business Practice Location Address Fax Number:
910-653-2304
Provider Enumeration Date:
07/19/2005