Provider First Line Business Practice Location Address: 
37 MEDICAL PARK LOOP
    Provider Second Line Business Practice Location Address: 
SUITE 103
    Provider Business Practice Location Address City Name: 
SYLVA
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
28779-5289
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
828-586-7466
    Provider Business Practice Location Address Fax Number: 
828-586-4512
    Provider Enumeration Date: 
12/18/2007