Provider First Line Business Practice Location Address:
130 BAKER STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLACKVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-284-1045
Provider Business Practice Location Address Fax Number:
803-284-3094
Provider Enumeration Date:
10/05/2006