Provider First Line Business Practice Location Address: 
201 N DUDLEY ST
    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: 
27401-3132
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
336-389-1297
    Provider Business Practice Location Address Fax Number: 
336-389-1618
    Provider Enumeration Date: 
06/20/2007