Provider First Line Business Practice Location Address:
146 EAST HOSPITAL DRIVE
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
WEST COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29169
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-936-7590
Provider Business Practice Location Address Fax Number:
803-936-7589
Provider Enumeration Date:
08/25/2006