Provider First Line Business Practice Location Address:
3160 NORTH RD
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:
29118-2805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-539-0694
Provider Business Practice Location Address Fax Number:
803-539-2914
Provider Enumeration Date:
11/15/2006