Provider First Line Business Practice Location Address:
1278 MOORE 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:
29560-4601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-389-7251
Provider Business Practice Location Address Fax Number:
843-389-7253
Provider Enumeration Date:
06/28/2006