Provider First Line Business Practice Location Address:
411 MEADOWLARK STREET
Provider Second Line Business Practice Location Address:
SHAW AIR FORCE BASE, SHAW AFB
Provider Business Practice Location Address City Name:
SUMTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29152-5019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-895-6064
Provider Business Practice Location Address Fax Number:
803-895-6539
Provider Enumeration Date:
11/22/2005