Provider First Line Business Practice Location Address:
1631 BROAD RIVER ROAD
Provider Second Line Business Practice Location Address:
BOOZER SHOPPING CENTER #B
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-772-9229
Provider Business Practice Location Address Fax Number:
803-731-0616
Provider Enumeration Date:
06/20/2006