Provider First Line Business Practice Location Address: 
620 E LEXINGTON AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HIGH POINT
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27262-2755
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
336-331-0907
    Provider Business Practice Location Address Fax Number: 
336-331-0909
    Provider Enumeration Date: 
03/15/2018