Provider First Line Business Practice Location Address: 
407 MUNSTER AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GREENSBORO
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27406-6713
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
336-275-2822
    Provider Business Practice Location Address Fax Number: 
336-335-9933
    Provider Enumeration Date: 
03/29/2007