Provider First Line Business Practice Location Address:
1330 RICHLAND STREET
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:
29201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-238-7040
Provider Business Practice Location Address Fax Number:
404-410-4053
Provider Enumeration Date:
10/11/2006