Provider First Line Business Practice Location Address:
1306 N FRASER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29440-2800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-546-3132
Provider Business Practice Location Address Fax Number:
843-546-2268
Provider Enumeration Date:
06/10/2005