Provider First Line Business Practice Location Address: 
123 SLOAN STREET
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CLEMSON
    Provider Business Practice Location Address State Name: 
SC
    Provider Business Practice Location Address Postal Code: 
29631
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
864-654-5652
    Provider Business Practice Location Address Fax Number: 
864-654-5652
    Provider Enumeration Date: 
09/20/2006