Provider First Line Business Practice Location Address: 
1134 N ROAD ST STE 2
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ELIZABETH CITY
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27909-3365
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
252-335-2923
    Provider Business Practice Location Address Fax Number: 
252-335-7003
    Provider Enumeration Date: 
03/23/2006