Provider First Line Business Practice Location Address:
208 E 2ND ST NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMMERVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29483
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-236-9196
Provider Business Practice Location Address Fax Number:
651-855-5270
Provider Enumeration Date:
08/20/2026