Provider First Line Business Practice Location Address: 
1115 DUNLAP RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ANDERSON
    Provider Business Practice Location Address State Name: 
SC
    Provider Business Practice Location Address Postal Code: 
29621-2501
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
864-226-2582
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/13/2006