Provider First Line Business Practice Location Address:
112 MEDICAL VILLAGE DR STE F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLACE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28466-1665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-285-0940
Provider Business Practice Location Address Fax Number:
910-285-1825
Provider Enumeration Date:
05/22/2007