Provider First Line Business Practice Location Address:
1205 PENDLETON ST
Provider Second Line Business Practice Location Address:
SUITE 341C
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29201-3756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-737-1601
Provider Business Practice Location Address Fax Number:
803-737-1610
Provider Enumeration Date:
11/06/2012