Provider First Line Business Practice Location Address:
102 NORTHSIDE PARK
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZABETH CITY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27909-9337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-335-4619
Provider Business Practice Location Address Fax Number:
252-335-5744
Provider Enumeration Date:
12/09/2005