Provider First Line Business Practice Location Address:
201 COLUMBIA MALL BLVD
Provider Second Line Business Practice Location Address:
SUITE 141
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29223-7536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-865-1068
Provider Business Practice Location Address Fax Number:
803-865-1089
Provider Enumeration Date:
11/19/2010