Provider First Line Business Practice Location Address: 
106 N HIGH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
EDEN
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27288-3912
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
504-256-6071
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/25/2014