Provider First Line Business Practice Location Address:
1205 HUTTO ST NE
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:
29118-1454
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-531-3911
Provider Business Practice Location Address Fax Number:
803-531-2666
Provider Enumeration Date:
08/15/2005