Provider First Line Business Practice Location Address: 
233 W MOUNTAIN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
KERNERSVILLE
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27284-2529
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
336-333-2559
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/03/2014