Provider First Line Business Practice Location Address:
608 JACKSON STREET
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ROANOKE RAPIDS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27870
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-813-8785
Provider Business Practice Location Address Fax Number:
252-537-0329
Provider Enumeration Date:
09/16/2008