Provider First Line Business Practice Location Address:
157 CENTRE 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:
29115-6043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-536-0405
Provider Business Practice Location Address Fax Number:
803-536-3533
Provider Enumeration Date:
12/12/2006