Provider First Line Business Practice Location Address: 
10990 BELTON HONEA PATH HWY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HONEA PATH
    Provider Business Practice Location Address State Name: 
SC
    Provider Business Practice Location Address Postal Code: 
29654-9506
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
305-332-5011
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/15/2014