Provider First Line Business Practice Location Address:
318 A MOORE STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-651-9235
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/15/2014