Provider First Line Business Practice Location Address:
1291 BROUGHTON ST
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:
29115-5967
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-531-3141
Provider Business Practice Location Address Fax Number:
803-531-3143
Provider Enumeration Date:
10/03/2006