Provider First Line Business Practice Location Address:
214 LAKE FRONT DRIVE
Provider Second Line Business Practice Location Address:
PHYSICIAN SERVICES
Provider Business Practice Location Address City Name:
COLA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-309-4788
Provider Business Practice Location Address Fax Number:
866-927-3065
Provider Enumeration Date:
10/09/2012