Provider First Line Business Practice Location Address:
9302 MEDICAL PLAZA DR
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29406-9142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-797-0416
Provider Business Practice Location Address Fax Number:
843-847-4477
Provider Enumeration Date:
08/17/2006