Provider First Line Business Practice Location Address:
3120 MARTIN LUTHER KING JR HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSTREE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29556-6798
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-382-2862
Provider Business Practice Location Address Fax Number:
843-382-2864
Provider Enumeration Date:
11/13/2006