Provider First Line Business Practice Location Address:
1228 HIGHWAY 72 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29649-1816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-943-0549
Provider Business Practice Location Address Fax Number:
864-227-2067
Provider Enumeration Date:
08/31/2005