Provider First Line Business Practice Location Address:
8452 N OLD WIRE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUMBER BRIDGE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28357-8926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-367-5702
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/18/2026