Provider First Line Business Practice Location Address: 
521 BRUMMELL LN
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HIGH POINT
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27265-3212
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
336-944-7609
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/06/2015