Provider First Line Business Practice Location Address:
2100 OLD HIGHWAY 17 N
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
NORTH MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29582-2242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-249-2500
Provider Business Practice Location Address Fax Number:
843-249-2544
Provider Enumeration Date:
10/18/2010