Provider First Line Business Practice Location Address:
914 RICHLAND ST
Provider Second Line Business Practice Location Address:
SUITE B 201
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:
803-779-0304
Provider Business Practice Location Address Fax Number:
803-765-8317
Provider Enumeration Date:
10/16/2006