Provider First Line Business Practice Location Address:
1201 MAIN ST
Provider Second Line Business Practice Location Address:
1980
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29201-3200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-219-1374
Provider Business Practice Location Address Fax Number:
803-748-1288
Provider Enumeration Date:
02/17/2011