Provider First Line Business Practice Location Address:
319 MERCY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CITY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29560-2331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-374-2825
Provider Business Practice Location Address Fax Number:
843-374-9914
Provider Enumeration Date:
02/28/2011