Provider First Line Business Practice Location Address:
968 DANTZLER 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:
29115-4322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-809-0003
Provider Business Practice Location Address Fax Number:
803-809-0004
Provider Enumeration Date:
07/15/2021