Provider First Line Business Practice Location Address:
718 KING 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:
29205-1706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-252-0676
Provider Business Practice Location Address Fax Number:
803-252-3939
Provider Enumeration Date:
05/10/2006