Provider First Line Business Practice Location Address: 
145 WILLIAMS PRIDE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BANNER ELK
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
28604-9990
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
336-420-0417
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/26/2014