Provider First Line Business Practice Location Address:
148 FOOTHILLS CTR DR
Provider Second Line Business Practice Location Address:
STE 148
Provider Business Practice Location Address City Name:
WEST UNION
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29696
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-240-0330
Provider Business Practice Location Address Fax Number:
717-240-0233
Provider Enumeration Date:
11/30/2006