Provider First Line Business Practice Location Address:
1300 WHEAT ST
Provider Second Line Business Practice Location Address:
BLATT PE CENTER, ROOM 218-P
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-777-7175
Provider Business Practice Location Address Fax Number:
803-777-6250
Provider Enumeration Date:
05/21/2007