Provider First Line Business Practice Location Address: 
698 HOWARD STREET
    Provider Second Line Business Practice Location Address: 
SPARTANBURG SCHOOL DISTRICT 7
    Provider Business Practice Location Address City Name: 
SPARTANBURG
    Provider Business Practice Location Address State Name: 
SC
    Provider Business Practice Location Address Postal Code: 
29303
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
864-594-4470
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/26/2012