Provider First Line Business Practice Location Address:
501 NORTH LONGSTREET STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSTREE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29556
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-354-5496
Provider Business Practice Location Address Fax Number:
854-354-3107
Provider Enumeration Date:
02/21/2007