Provider First Line Business Practice Location Address:
812 CANDY PARK ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEMBROKE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-522-1041
Provider Business Practice Location Address Fax Number:
910-522-1085
Provider Enumeration Date:
10/11/2006