Provider First Line Business Practice Location Address: 
676 NW BROAD ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SOUTHERN PINES
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
28387-4105
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
910-692-0683
    Provider Business Practice Location Address Fax Number: 
910-695-0766
    Provider Enumeration Date: 
12/11/2014