Provider First Line Business Practice Location Address:
606 BLACK RIVER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29440-3304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-527-7171
Provider Business Practice Location Address Fax Number:
843-520-7882
Provider Enumeration Date:
02/03/2006