Provider First Line Business Practice Location Address:
3681 LEAPHART RD
Provider Second Line Business Practice Location Address:
STE D
Provider Business Practice Location Address City Name:
WEST COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29169-3068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-796-0855
Provider Business Practice Location Address Fax Number:
803-796-0028
Provider Enumeration Date:
02/02/2006