Provider First Line Business Practice Location Address: 
1519 N MAIN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
TARBORO
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27886-2519
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
252-824-0342
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/23/2014