Provider First Line Business Practice Location Address: 
321 MULBERRY ST SW
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LENOIR
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
28645-5720
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
828-757-5504
    Provider Business Practice Location Address Fax Number: 
828-757-5501
    Provider Enumeration Date: 
04/16/2013