Provider First Line Business Practice Location Address: 
214 S. VAN LINGLE MUNGO BLVD.
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PAGELAND
    Provider Business Practice Location Address State Name: 
SC
    Provider Business Practice Location Address Postal Code: 
29728
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
843-675-2323
    Provider Business Practice Location Address Fax Number: 
843-675-2025
    Provider Enumeration Date: 
06/01/2007