Provider First Line Business Practice Location Address: 
508 E. MCKAY ST.
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ELIZABETHTOWN
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
28337
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
252-292-1349
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/16/2023