Provider First Line Business Practice Location Address:
1850 LAUREL ST
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29201-2627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-296-7305
Provider Business Practice Location Address Fax Number:
803-296-7329
Provider Enumeration Date:
06/25/2009