Provider First Line Business Practice Location Address: 
1801 E 5TH ST STE 101
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CHARLOTTE
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
28204-2472
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
415-302-2573
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/11/2007