Provider First Line Business Practice Location Address:
3249 ALLENDALE FAIRFAX HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRFAX
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29827-9163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-584-4603
Provider Business Practice Location Address Fax Number:
803-584-5303
Provider Enumeration Date:
05/09/2006