Provider First Line Business Practice Location Address:
1122 LADY ST STE 100
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:
29201-3469
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
980-949-0364
Provider Business Practice Location Address Fax Number:
801-992-8269
Provider Enumeration Date:
04/22/2026