Provider First Line Business Practice Location Address: 
330 BILLINGSLEY ROAD
    Provider Second Line Business Practice Location Address: 
STE 204
    Provider Business Practice Location Address City Name: 
CHARLOTTE
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
28211
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
704-365-9871
    Provider Business Practice Location Address Fax Number: 
704-365-9898
    Provider Enumeration Date: 
12/29/2007