Provider First Line Business Practice Location Address:
1600 LAKE MURRAY BLVD
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:
29212-8623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-731-9600
Provider Business Practice Location Address Fax Number:
803-731-0297
Provider Enumeration Date:
05/19/2011