Provider First Line Business Practice Location Address:
7 MEDICAL PARK
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-434-3400
Provider Business Practice Location Address Fax Number:
803-434-3938
Provider Enumeration Date:
11/10/2005