Provider First Line Business Practice Location Address:
2482 POWELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29440-8590
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-887-3274
Provider Business Practice Location Address Fax Number:
843-887-3817
Provider Enumeration Date:
10/13/2006