Provider First Line Business Practice Location Address:
3400 HARDEN STREET EXT
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-569-4373
Provider Business Practice Location Address Fax Number:
803-569-4379
Provider Enumeration Date:
07/18/2006