Provider First Line Business Practice Location Address:
2199 NORTH FRAZER ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29440-6409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-527-6835
Provider Business Practice Location Address Fax Number:
843-527-3665
Provider Enumeration Date:
07/28/2014