Provider First Line Business Practice Location Address: 
416 S KING ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LAURINBURG
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
28352-3704
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
910-276-3313
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/31/2014