Provider First Line Business Practice Location Address: 
4057 HIGHWAY 17
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MURRELLS INLET
    Provider Business Practice Location Address State Name: 
SC
    Provider Business Practice Location Address Postal Code: 
29576-5032
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
843-235-3131
    Provider Business Practice Location Address Fax Number: 
843-237-9646
    Provider Enumeration Date: 
11/02/2007