Provider First Line Business Practice Location Address: 
300 COLUMBIA AVE
    Provider Second Line Business Practice Location Address: 
CHAPIN HIGH SCHOOL
    Provider Business Practice Location Address City Name: 
CHAPIN
    Provider Business Practice Location Address State Name: 
SC
    Provider Business Practice Location Address Postal Code: 
29036
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
803-575-5409
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/11/2013