Provider First Line Business Practice Location Address:
3791 CHARLESTON HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGEBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-465-1238
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/23/2013