Provider First Line Business Practice Location Address: 
269 S CHURCH ST
    Provider Second Line Business Practice Location Address: 
SUITE 216
    Provider Business Practice Location Address City Name: 
SPARTANBURG
    Provider Business Practice Location Address State Name: 
SC
    Provider Business Practice Location Address Postal Code: 
29306-3496
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
904-207-8295
    Provider Business Practice Location Address Fax Number: 
864-877-2473
    Provider Enumeration Date: 
12/04/2014