Provider First Line Business Practice Location Address:
679 ORANGEBURG ROAD
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
SUMMERVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29483
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-209-6375
Provider Business Practice Location Address Fax Number:
843-225-0348
Provider Enumeration Date:
04/03/2007