Provider First Line Business Practice Location Address: 
10187 DUNBARTON BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BARNWELL
    Provider Business Practice Location Address State Name: 
SC
    Provider Business Practice Location Address Postal Code: 
29812-1418
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
803-259-5391
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/23/2014