Provider First Line Business Practice Location Address:
230 ELLIOTT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGEBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29115-6022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-534-6567
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/25/2008