Provider First Line Business Practice Location Address:
1120 SPARKLEBERRY LANE EXT
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29223-7078
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-462-3662
Provider Business Practice Location Address Fax Number:
803-462-6865
Provider Enumeration Date:
09/26/2006