Provider First Line Business Practice Location Address:
146 E. HOSPITAL DR.
Provider Second Line Business Practice Location Address:
SUITE 550
Provider Business Practice Location Address City Name:
WEST COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-936-7410
Provider Business Practice Location Address Fax Number:
803-936-7412
Provider Enumeration Date:
06/30/2005