Provider First Line Business Practice Location Address:
1301 TAYLOR ST
Provider Second Line Business Practice Location Address:
SUITE 1A
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:
803-254-4591
Provider Business Practice Location Address Fax Number:
803-931-8000
Provider Enumeration Date:
07/27/2006