Provider First Line Business Practice Location Address:
4730 BETHEL CHURCH RD
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:
29206-1210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-318-2939
Provider Business Practice Location Address Fax Number:
803-782-1353
Provider Enumeration Date:
01/29/2010