Provider First Line Business Practice Location Address:
210 E 15TH ST
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:
28358-1205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-816-0101
Provider Business Practice Location Address Fax Number:
910-739-4681
Provider Enumeration Date:
10/29/2012