Provider First Line Business Practice Location Address: 
183 OLD TURNPIKE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MILLS RIVER
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
28759-8776
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
770-639-9657
    Provider Business Practice Location Address Fax Number: 
828-350-1300
    Provider Enumeration Date: 
07/29/2016