Provider First Line Business Practice Location Address:
1685 CANAL RD
Provider Second Line Business Practice Location Address:
C/O 1698 CANAL RD
Provider Business Practice Location Address City Name:
PEMBROKE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28372-9343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-318-9667
Provider Business Practice Location Address Fax Number:
910-522-7327
Provider Enumeration Date:
01/15/2010