Provider First Line Business Practice Location Address:
200 OUTLET POINTE BLVD
Provider Second Line Business Practice Location Address:
ATTN: MANAGED CARE DEPT.
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29210-5667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-798-7660
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/08/2006