Provider First Line Business Practice Location Address: 
950 W FARIS RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GREENVILLE
    Provider Business Practice Location Address State Name: 
SC
    Provider Business Practice Location Address Postal Code: 
29605-4255
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
864-271-3444
    Provider Business Practice Location Address Fax Number: 
864-271-4471
    Provider Enumeration Date: 
06/03/2013