Provider First Line Business Practice Location Address:
1184 JACKSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARNWELL
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29812-2162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-259-2512
Provider Business Practice Location Address Fax Number:
803-254-2514
Provider Enumeration Date:
01/12/2009