Provider First Line Business Practice Location Address:
115 S MORRIS 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:
29560-2459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-394-3605
Provider Business Practice Location Address Fax Number:
843-394-1042
Provider Enumeration Date:
01/08/2009