Provider First Line Business Practice Location Address:
1235 JOHNSON AVE
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:
29203-5859
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-939-6420
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/12/2026