Provider First Line Business Practice Location Address:
7964 COUNTY LINE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIBERTY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27298-9590
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-622-2754
Provider Business Practice Location Address Fax Number:
336-622-1420
Provider Enumeration Date:
04/28/2009