Provider First Line Business Practice Location Address:
125 WADE ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
WEST COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29169-4635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-794-4460
Provider Business Practice Location Address Fax Number:
803-794-4669
Provider Enumeration Date:
11/16/2005