Provider First Line Business Practice Location Address: 
216 MOORE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
KING
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27021-8703
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
336-983-4346
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
05/26/2016