Provider First Line Business Practice Location Address:
1901 BLANDING ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29201-3581
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-779-8303
Provider Business Practice Location Address Fax Number:
803-779-2198
Provider Enumeration Date:
12/27/2010