Provider First Line Business Practice Location Address:
1333 TAYLOR ST
Provider Second Line Business Practice Location Address:
SUITE 2A
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29201-2923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-296-3429
Provider Business Practice Location Address Fax Number:
803-296-2735
Provider Enumeration Date:
12/27/2011