Provider First Line Business Practice Location Address:
2934 N ELM ST STE B1
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-272-9675
Provider Business Practice Location Address Fax Number:
910-272-9676
Provider Enumeration Date:
10/14/2005