Provider First Line Business Practice Location Address:
2055 WEDGEFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29154-4654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-773-5979
Provider Business Practice Location Address Fax Number:
803-773-6088
Provider Enumeration Date:
12/28/2012