Provider First Line Business Practice Location Address:
76 IRVING ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARNWELL
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29812-1500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-259-9412
Provider Business Practice Location Address Fax Number:
803-259-0559
Provider Enumeration Date:
11/29/2012