Provider First Line Business Practice Location Address:
4145 HARD SCRABBLE RD
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:
29223-8563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-865-2024
Provider Business Practice Location Address Fax Number:
775-703-5483
Provider Enumeration Date:
10/19/2006