Provider First Line Business Practice Location Address:
130 BROAD ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SUMTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29150-4237
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-774-4377
Provider Business Practice Location Address Fax Number:
803-774-4378
Provider Enumeration Date:
02/07/2008