Provider First Line Business Practice Location Address:
115 N SUMTER ST
Provider Second Line Business Practice Location Address:
STE 315
Provider Business Practice Location Address City Name:
SUMTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29150-4967
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-934-0810
Provider Business Practice Location Address Fax Number:
803-934-0809
Provider Enumeration Date:
06/22/2005