Provider First Line Business Practice Location Address:
107 CHURCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE WACCAMAW
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28450-1909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-803-1620
Provider Business Practice Location Address Fax Number:
215-902-4882
Provider Enumeration Date:
07/19/2010