Provider First Line Business Practice Location Address:
230 E W T HARRIS BLVD
Provider Second Line Business Practice Location Address:
SUITE C-13
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28262-3492
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-688-0324
Provider Business Practice Location Address Fax Number:
704-549-8043
Provider Enumeration Date:
12/15/2006