Provider First Line Business Practice Location Address:
190 KIMEL PARK RD
Provider Second Line Business Practice Location Address:
VA OUTPATIENT CLINIC
Provider Business Practice Location Address City Name:
WINSTON-SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-768-3296
Provider Business Practice Location Address Fax Number:
336-760-5496
Provider Enumeration Date:
03/24/2006