Provider First Line Business Practice Location Address:
1643 CAROLINA AVENUE
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:
803-534-7525
Provider Business Practice Location Address Fax Number:
803-534-7526
Provider Enumeration Date:
12/05/2006