Provider First Line Business Practice Location Address:
106 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LATTA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29565-1617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
842-752-0023
Provider Business Practice Location Address Fax Number:
843-752-0062
Provider Enumeration Date:
11/21/2005