Provider First Line Business Practice Location Address:
106 E THOMAS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CITY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29560-2639
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-229-8504
Provider Business Practice Location Address Fax Number:
866-285-0122
Provider Enumeration Date:
08/05/2007