Provider First Line Business Practice Location Address:
1425 RUSSELL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGEBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29115-6070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-534-5727
Provider Business Practice Location Address Fax Number:
803-531-2837
Provider Enumeration Date:
09/20/2006