Provider First Line Business Practice Location Address:
408 DEKALB ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
CAMDEN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29020-4429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-424-1142
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/23/2005