Provider First Line Business Practice Location Address:
3800 N MAIN ST STE B
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:
29203-6446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-705-3172
Provider Business Practice Location Address Fax Number:
803-705-3173
Provider Enumeration Date:
10/31/2005