Provider First Line Business Practice Location Address:
237 LELA HARRISON ROAD
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:
843-382-5927
Provider Business Practice Location Address Fax Number:
843-382-5826
Provider Enumeration Date:
11/08/2006