Provider First Line Business Practice Location Address: 
1600 HARRY BYRD HWY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DARLINGTON
    Provider Business Practice Location Address State Name: 
SC
    Provider Business Practice Location Address Postal Code: 
29532-3516
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
843-393-4230
    Provider Business Practice Location Address Fax Number: 
843-393-7131
    Provider Enumeration Date: 
12/30/2005