Provider First Line Business Practice Location Address: 
1214 VAUGHN RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BURLINGTON
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27217-2863
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
336-532-0000
    Provider Business Practice Location Address Fax Number: 
336-532-0001
    Provider Enumeration Date: 
09/18/2008