Provider First Line Business Practice Location Address:
5423 LAKE WILSON RD
Provider Second Line Business Practice Location Address:
BOX 44
Provider Business Practice Location Address City Name:
ELM CITY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27822-0044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-236-4664
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2012