Provider First Line Business Practice Location Address:
1615 MIDDLETON ST
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:
29115-4885
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-534-0964
Provider Business Practice Location Address Fax Number:
803-534-2517
Provider Enumeration Date:
02/29/2008