Provider First Line Business Practice Location Address:
312 KING STREET
Provider Second Line Business Practice Location Address:
CENTRA SOUTHSIDE PROFESSIONAL LLC
Provider Business Practice Location Address City Name:
KEYSVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23937-3659
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-315-2998
Provider Business Practice Location Address Fax Number:
434-392-8191
Provider Enumeration Date:
01/27/2006