Provider First Line Business Practice Location Address:
748 ORANGEBURG RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMMERVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29483-8934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-832-8606
Provider Business Practice Location Address Fax Number:
843-285-7272
Provider Enumeration Date:
09/16/2005