Provider First Line Business Practice Location Address:
1301 TAYLOR ST
Provider Second Line Business Practice Location Address:
SUITE 5-K
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29201-2942
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-765-2090
Provider Business Practice Location Address Fax Number:
803-765-0580
Provider Enumeration Date:
07/21/2008