Provider First Line Business Practice Location Address: 
12253 HERITAGE HWY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BAMBERG
    Provider Business Practice Location Address State Name: 
SC
    Provider Business Practice Location Address Postal Code: 
29003-1678
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
803-645-8842
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/26/2014