Provider First Line Business Practice Location Address: 
1076 STAMPER RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FAYETTEVILLE
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
28303-4191
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
910-483-2002
    Provider Business Practice Location Address Fax Number: 
910-483-4004
    Provider Enumeration Date: 
11/29/2006