Provider First Line Business Practice Location Address:
1850 LAUREL ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29201-2627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-929-1901
Provider Business Practice Location Address Fax Number:
803-929-1916
Provider Enumeration Date:
02/05/2008