Provider First Line Business Practice Location Address:
1605 CAROLINA AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGEBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29115-4939
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-534-2352
Provider Business Practice Location Address Fax Number:
803-534-2180
Provider Enumeration Date:
02/19/2009