Provider First Line Business Practice Location Address:
1730 HENDERSON ST
Provider Second Line Business Practice Location Address:
SUITE C
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:
803-765-2600
Provider Business Practice Location Address Fax Number:
803-799-6434
Provider Enumeration Date:
07/11/2006