Provider First Line Business Practice Location Address:
115 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMMERTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29148-6904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-485-8725
Provider Business Practice Location Address Fax Number:
803-485-4306
Provider Enumeration Date:
12/14/2005