Provider First Line Business Practice Location Address:
1518 PICKENS ST STE A
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:
29201-3449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-306-6121
Provider Business Practice Location Address Fax Number:
803-306-6122
Provider Enumeration Date:
04/17/2006