Provider First Line Business Practice Location Address:
124 FIRE TOWER RD
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:
29118-1401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-531-6202
Provider Business Practice Location Address Fax Number:
803-534-5263
Provider Enumeration Date:
04/04/2006