Provider First Line Business Practice Location Address:
1101 ELMWOOD AVE
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29201-2172
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-758-4000
Provider Business Practice Location Address Fax Number:
803-758-4001
Provider Enumeration Date:
05/07/2008