Provider First Line Business Practice Location Address:
1309 LANTERN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMMERVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29486-2087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-690-7589
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/24/2026