Provider First Line Business Practice Location Address:
1 WELLNESS BLVD STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRMO
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29063-2872
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-419-4235
Provider Business Practice Location Address Fax Number:
803-419-4236
Provider Enumeration Date:
07/13/2005