Provider First Line Business Practice Location Address:
1346 WINGATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGEBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29118-2443
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-531-1799
Provider Business Practice Location Address Fax Number:
803-531-8308
Provider Enumeration Date:
12/06/2005