Provider First Line Business Practice Location Address: 
770 S RON MCNAIR BLVD
    Provider Second Line Business Practice Location Address: 
UNIT A
    Provider Business Practice Location Address City Name: 
LAKE CITY
    Provider Business Practice Location Address State Name: 
SC
    Provider Business Practice Location Address Postal Code: 
29560-3824
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
843-374-7480
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/24/2007