Provider First Line Business Practice Location Address: 
803 N FANT ST STE 3A
    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: 
29621-5718
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
864-437-8444
    Provider Business Practice Location Address Fax Number: 
864-437-8448
    Provider Enumeration Date: 
12/04/2012