Provider First Line Business Practice Location Address:
7209 HWY 90
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
LONGS
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-390-1800
Provider Business Practice Location Address Fax Number:
843-390-1817
Provider Enumeration Date:
12/08/2009