Provider First Line Business Practice Location Address:
50 PROMISED LAND RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDGEFIELD
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29824-3349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-480-1896
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/23/2023