Provider First Line Business Practice Location Address: 
2300 W MEADOWVIEW RD
    Provider Second Line Business Practice Location Address: 
SUITE 124
    Provider Business Practice Location Address City Name: 
GREENSBORO
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27407-3720
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
336-764-1000
    Provider Business Practice Location Address Fax Number: 
336-603-5967
    Provider Enumeration Date: 
07/24/2011