Provider First Line Business Practice Location Address:
2514 SUMTER ST
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:
29201-1938
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-771-4112
Provider Business Practice Location Address Fax Number:
803-771-4118
Provider Enumeration Date:
01/03/2007