Provider First Line Business Practice Location Address:
715 SUMTER ST
Provider Second Line Business Practice Location Address:
ROOM 314A
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29208-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-777-6058
Provider Business Practice Location Address Fax Number:
803-777-1943
Provider Enumeration Date:
10/20/2005