Provider First Line Business Practice Location Address:
1619 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:
29115-4939
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-531-7474
Provider Business Practice Location Address Fax Number:
803-531-7457
Provider Enumeration Date:
11/11/2011