Provider First Line Business Practice Location Address: 
316 LILLINGTON AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CHARLOTTE
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
28204-3130
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
980-225-5414
    Provider Business Practice Location Address Fax Number: 
980-225-5414
    Provider Enumeration Date: 
09/13/2010