Provider First Line Business Practice Location Address: 
2012 S ELM EUGENE ST
    Provider Second Line Business Practice Location Address: 
SUITE B
    Provider Business Practice Location Address City Name: 
GREENSBORO
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27406-2825
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
336-617-3572
    Provider Business Practice Location Address Fax Number: 
336-617-3582
    Provider Enumeration Date: 
07/03/2009