Provider First Line Business Practice Location Address:
1080 SUMMERS 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:
29115-4920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-539-0084
Provider Business Practice Location Address Fax Number:
803-539-0097
Provider Enumeration Date:
04/05/2006