Provider First Line Business Practice Location Address:
1138 N ROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZABETH CITY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27909-3353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-312-4047
Provider Business Practice Location Address Fax Number:
757-410-0339
Provider Enumeration Date:
06/30/2008