Provider First Line Business Practice Location Address:
143 ROSEDALE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZABETH CITY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27909-9810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-331-2965
Provider Business Practice Location Address Fax Number:
252-335-0329
Provider Enumeration Date:
10/26/2006