Provider First Line Business Practice Location Address: 
22580 HIGHWAY 76 E
    Provider Second Line Business Practice Location Address: 
SUITE 300
    Provider Business Practice Location Address City Name: 
LAURENS
    Provider Business Practice Location Address State Name: 
SC
    Provider Business Practice Location Address Postal Code: 
29360-8439
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
864-939-1070
    Provider Business Practice Location Address Fax Number: 
864-939-1079
    Provider Enumeration Date: 
08/27/2014