Provider First Line Business Practice Location Address: 
16715 OLD STATESVILLE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HUNTERSVILLE
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
28078-9583
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
704-655-2710
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/13/2011