Provider First Line Business Practice Location Address:
1105 N. LAFAYETTE DR
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SUMTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29150-2984
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-774-3600
Provider Business Practice Location Address Fax Number:
803-774-4560
Provider Enumeration Date:
08/17/2005