Provider First Line Business Practice Location Address:
2117 GERVAIS STREET
Provider Second Line Business Practice Location Address:
WAVERLY FAMILY PRATICE
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-748-1181
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/12/2008