Provider First Line Business Practice Location Address:
2 MEDICAL PARK RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29203-6875
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-434-6781
Provider Business Practice Location Address Fax Number:
803-434-8377
Provider Enumeration Date:
10/18/2006