Provider First Line Business Practice Location Address: 
708 UMSTEAD LN
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GARNER
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27529-3099
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
919-779-2424
    Provider Business Practice Location Address Fax Number: 
919-779-5235
    Provider Enumeration Date: 
11/14/2006