Provider First Line Business Practice Location Address: 
2600 NC HIGHWAY 97
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WENDELL
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27591-9319
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
919-279-8316
    Provider Business Practice Location Address Fax Number: 
919-365-7215
    Provider Enumeration Date: 
07/07/2016