Provider First Line Business Practice Location Address:
12611 N COMMUNITY HOUSE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28277-3816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-731-1014
Provider Business Practice Location Address Fax Number:
704-731-1376
Provider Enumeration Date:
09/23/2016