Provider First Line Business Practice Location Address: 
4606 PARRIS BRIGDE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BOILING SPRINGS
    Provider Business Practice Location Address State Name: 
SC
    Provider Business Practice Location Address Postal Code: 
29316
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
864-578-2610
    Provider Business Practice Location Address Fax Number: 
864-578-2620
    Provider Enumeration Date: 
05/07/2013