Provider First Line Business Practice Location Address: 
714 ARNETTE AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DURHAM
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27701-3105
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
919-425-0974
    Provider Business Practice Location Address Fax Number: 
336-375-0046
    Provider Enumeration Date: 
04/17/2007