Provider First Line Business Practice Location Address: 
1051 SILVER BLUFF RD STE A
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
AIKEN
    Provider Business Practice Location Address State Name: 
SC
    Provider Business Practice Location Address Postal Code: 
29803-5855
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
803-642-4339
    Provider Business Practice Location Address Fax Number: 
803-649-6799
    Provider Enumeration Date: 
08/12/2009