Provider First Line Business Practice Location Address: 
2630 WILLARD DAIRY RD
    Provider Second Line Business Practice Location Address: 
SUITE 300
    Provider Business Practice Location Address City Name: 
HIGH POINT
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27265-8351
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
336-884-3888
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
05/01/2015