Provider First Line Business Practice Location Address:
1787 ALLENDALE FAIRFAX HIGHWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRFAX
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-632-3421
Provider Business Practice Location Address Fax Number:
803-632-2410
Provider Enumeration Date:
01/10/2007