Provider First Line Business Practice Location Address:
4110 MOSEBY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29207-6118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-790-1849
Provider Business Practice Location Address Fax Number:
803-790-1846
Provider Enumeration Date:
06/29/2006