Provider First Line Business Practice Location Address:
210 E 15TH 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:
28358-4763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-671-6769
Provider Business Practice Location Address Fax Number:
910-401-1004
Provider Enumeration Date:
12/26/2007