Provider First Line Business Practice Location Address:
571 MEMORIAL AVENUE NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALLENDALE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-584-3818
Provider Business Practice Location Address Fax Number:
803-584-8107
Provider Enumeration Date:
10/12/2006