Provider First Line Business Practice Location Address:
2418 DEVINE ST
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-920-4491
Provider Business Practice Location Address Fax Number:
803-256-5020
Provider Enumeration Date:
01/18/2007