Provider First Line Business Practice Location Address: 
1502 GODWIN AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LUMBERTON
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
28358-4206
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
910-738-1108
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/09/2006