Provider First Line Business Practice Location Address:
9313 MEDICAL PLAZA DR
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29406-9155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-797-8992
Provider Business Practice Location Address Fax Number:
843-797-4071
Provider Enumeration Date:
04/07/2006