Provider First Line Business Practice Location Address:
1075 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:
29440-2848
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-546-5128
Provider Business Practice Location Address Fax Number:
843-527-4027
Provider Enumeration Date:
11/21/2005