Provider First Line Business Practice Location Address:
235 ELLIOTT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGEBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29115-6021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-536-1634
Provider Business Practice Location Address Fax Number:
803-536-1604
Provider Enumeration Date:
06/10/2005