Provider First Line Business Practice Location Address:
110 YE OLDE KINGS HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29582-3050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-663-0770
Provider Business Practice Location Address Fax Number:
843-663-0772
Provider Enumeration Date:
10/27/2006