Provider First Line Business Practice Location Address:
1168 DOUGLAS MACARTHUR 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:
29115-7681
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-268-0813
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/22/2009