Provider First Line Business Practice Location Address:
14 MEDICAL PARK DRIVE
Provider Second Line Business Practice Location Address:
SUITE 320
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-434-8721
Provider Business Practice Location Address Fax Number:
803-434-3955
Provider Enumeration Date:
09/09/2008