Provider First Line Business Practice Location Address: 
5449 TRADE ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HOPE MILLS
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
28348-1939
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
910-429-3425
    Provider Business Practice Location Address Fax Number: 
910-429-3426
    Provider Enumeration Date: 
03/22/2011