Provider First Line Business Practice Location Address: 
2001 VAIL AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CHARLOTTE
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
28207-1248
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
704-973-5500
    Provider Business Practice Location Address Fax Number: 
727-328-9555
    Provider Enumeration Date: 
06/28/2011