Provider First Line Business Practice Location Address:
1983 CAROLINA AVE
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:
29115-4362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-534-3656
Provider Business Practice Location Address Fax Number:
803-534-1575
Provider Enumeration Date:
06/11/2006