Provider First Line Business Practice Location Address:
215 LEGARE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LATTA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29565-1824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-752-7479
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/30/2011