Provider First Line Business Practice Location Address:
4450 BROADRIVER RD.
Provider Second Line Business Practice Location Address:
DEPT. OF CORRECTIONS
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-896-1258
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/01/2007