Provider First Line Business Practice Location Address:
PEDS DEPT - 14 MEDICAL PARK
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-434-6155
Provider Business Practice Location Address Fax Number:
803-434-6979
Provider Enumeration Date:
06/22/2012