Provider First Line Business Practice Location Address:
5211 N TRENHOLM 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-782-0965
Provider Business Practice Location Address Fax Number:
803-782-3404
Provider Enumeration Date:
10/24/2006