Provider First Line Business Practice Location Address:
1275 ALLENDALE FAIRFAX HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRFAX
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29827-9124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-632-2055
Provider Business Practice Location Address Fax Number:
803-632-1708
Provider Enumeration Date:
12/18/2006