Provider First Line Business Practice Location Address:
147 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAGENER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29164-9442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-564-6000
Provider Business Practice Location Address Fax Number:
803-564-6011
Provider Enumeration Date:
01/26/2011