Provider First Line Business Practice Location Address: 
100 HEALTHY WAY
    Provider Second Line Business Practice Location Address: 
SUITE 1200
    Provider Business Practice Location Address City Name: 
ANDERSON
    Provider Business Practice Location Address State Name: 
SC
    Provider Business Practice Location Address Postal Code: 
29621-2067
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
864-328-0173
    Provider Business Practice Location Address Fax Number: 
864-328-0175
    Provider Enumeration Date: 
04/24/2007