Provider First Line Business Practice Location Address:
994 CHICKEN CORNER RD
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:
27909-8545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-338-6648
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/24/2011