Provider First Line Business Practice Location Address:
100 W MAIN 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:
28466-2902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-285-3101
Provider Business Practice Location Address Fax Number:
910-285-5834
Provider Enumeration Date:
10/07/2006