Provider First Line Business Practice Location Address:
3519 MEDICAL DR
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:
29203-6504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-799-2490
Provider Business Practice Location Address Fax Number:
803-540-7223
Provider Enumeration Date:
12/05/2006