Provider First Line Business Practice Location Address:
1415 HWY 17 BUS NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29577
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-238-5159
Provider Business Practice Location Address Fax Number:
843-238-5150
Provider Enumeration Date:
06/19/2006