Provider First Line Business Practice Location Address:
3518 OLD LAMPLIGHTER RD
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:
29206-3420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-909-7648
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/30/2007