Provider First Line Business Practice Location Address: 
1112 MILL ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CAMDEN
    Provider Business Practice Location Address State Name: 
SC
    Provider Business Practice Location Address Postal Code: 
29020-3712
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
803-432-4448
    Provider Business Practice Location Address Fax Number: 
803-432-2219
    Provider Enumeration Date: 
12/07/2020