Provider First Line Business Practice Location Address:
85 LICK FORK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDGEFIELD
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29824-3358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-631-7288
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/12/2014