Provider First Line Business Practice Location Address:
100 RIDGE MEDICAL PLAZA RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
EDGEFIELD
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29824-4535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-637-3630
Provider Business Practice Location Address Fax Number:
803-637-5348
Provider Enumeration Date:
12/11/2006