Provider First Line Business Practice Location Address:
13534 PLAZA ROAD EXTENSION
Provider Second Line Business Practice Location Address:
SUITE 128
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28215-7568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-750-5371
Provider Business Practice Location Address Fax Number:
704-313-9884
Provider Enumeration Date:
08/28/2012