Provider First Line Business Practice Location Address: 
204 N FIFTH ST STE H
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MEBANE
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27302-2519
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
336-512-2675
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/01/2020