Provider First Line Business Practice Location Address:
1558 ELLIS AVE
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:
29118-2514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-957-7111
Provider Business Practice Location Address Fax Number:
803-957-7115
Provider Enumeration Date:
08/23/2005