Provider First Line Business Practice Location Address: 
1380 COWELL FARM RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WASHINGTON
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27889-3431
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
252-946-0900
    Provider Business Practice Location Address Fax Number: 
252-946-0900
    Provider Enumeration Date: 
04/21/2009