Provider First Line Business Practice Location Address:
802 13TH AVENUE SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29582-3816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-272-1717
Provider Business Practice Location Address Fax Number:
843-272-4338
Provider Enumeration Date:
10/17/2006