Provider First Line Business Practice Location Address: 
1190 US HWY 1 NORTH
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
YOUNGSVILLE
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27596
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
919-554-1183
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/07/2011