Provider First Line Business Practice Location Address:
2214 WALLACE ST
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:
29201-1942
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-351-8454
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/26/2009