Provider First Line Business Practice Location Address:
3581 LACKEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUMBERTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28360-9048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-738-5023
Provider Business Practice Location Address Fax Number:
910-738-1581
Provider Enumeration Date:
10/17/2012