Provider First Line Business Practice Location Address:
11560 HWY 55 EAST
Provider Second Line Business Practice Location Address:
UNIT 13
Provider Business Practice Location Address City Name:
GRANTSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28529-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-745-3911
Provider Business Practice Location Address Fax Number:
252-745-1223
Provider Enumeration Date:
05/04/2011