Provider First Line Business Practice Location Address:
9304 MEDICAL PLAZA DR
Provider Second Line Business Practice Location Address:
UNIT C
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29406-9143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-572-0225
Provider Business Practice Location Address Fax Number:
843-797-5512
Provider Enumeration Date:
07/02/2008