Provider First Line Business Practice Location Address: 
2140 W ARLINGTON BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GREENVILLE
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
27834-5709
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
252-355-5252
    Provider Business Practice Location Address Fax Number: 
252-355-7776
    Provider Enumeration Date: 
10/24/2006