Provider First Line Business Practice Location Address:
4300 NORTH MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29203-5950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-691-5700
Provider Business Practice Location Address Fax Number:
803-691-5701
Provider Enumeration Date:
10/18/2006