Provider First Line Business Practice Location Address:
615 E SOUTHERLAND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLACE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28466-0070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-285-4410
Provider Business Practice Location Address Fax Number:
910-285-7505
Provider Enumeration Date:
08/31/2005