Provider First Line Business Practice Location Address:
3209 COLONIAL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-434-6113
Provider Business Practice Location Address Fax Number:
803-434-7231
Provider Enumeration Date:
10/26/2006