Provider First Line Business Practice Location Address:
1335 ELIZABETH AVE.
Provider Second Line Business Practice Location Address:
BELK 3157
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28235-5009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-330-6749
Provider Business Practice Location Address Fax Number:
704-330-6410
Provider Enumeration Date:
09/30/2007