Provider First Line Business Practice Location Address:
115 E MAIN ST STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLACE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28466-2746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-285-4954
Provider Business Practice Location Address Fax Number:
910-285-8603
Provider Enumeration Date:
10/31/2006