Provider First Line Business Practice Location Address: 
113 SALUDA SHORES CIR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LEESVILLE
    Provider Business Practice Location Address State Name: 
SC
    Provider Business Practice Location Address Postal Code: 
29070-7235
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
803-920-7871
    Provider Business Practice Location Address Fax Number: 
803-234-2927
    Provider Enumeration Date: 
04/20/2015