Provider First Line Business Practice Location Address:
520 THURGOOD MARSHALL BLVD.
Provider Second Line Business Practice Location Address:
SUITE B
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:
843-355-5628
Provider Business Practice Location Address Fax Number:
843-355-6072
Provider Enumeration Date:
06/14/2006