Provider First Line Business Practice Location Address:
112 1/2 ASHLEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29401-1249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-723-5346
Provider Business Practice Location Address Fax Number:
843-723-0660
Provider Enumeration Date:
04/24/2007