Provider First Line Business Practice Location Address:
9279 MEDICAL PLAZA DR
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29406-9141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-553-2223
Provider Business Practice Location Address Fax Number:
843-553-2275
Provider Enumeration Date:
02/20/2006