Provider First Line Business Practice Location Address:
1511 CAROLINA AVE
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:
29115-4940
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-539-0505
Provider Business Practice Location Address Fax Number:
803-539-0410
Provider Enumeration Date:
10/10/2006