Provider First Line Business Practice Location Address: 
1310 S CANNON BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
KANNAPOLIS
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
28083-6233
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
704-938-7021
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/04/2009