Provider First Line Business Practice Location Address:
905 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:
29115-5062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-747-5606
Provider Business Practice Location Address Fax Number:
803-937-6032
Provider Enumeration Date:
05/23/2019