Provider First Line Business Practice Location Address: 
812 W KING ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
KINGS MOUNTAIN
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
28086-2748
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
704-739-5456
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/16/2021