Provider First Line Business Practice Location Address: 
101 SPRUNT ST RM 127
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CHAPEL HILL
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27517-7810
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
984-974-2560
    Provider Business Practice Location Address Fax Number: 
919-843-2195
    Provider Enumeration Date: 
08/01/2009