Provider First Line Business Practice Location Address: 
818 HARDEN 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: 
29205-1002
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
803-799-0043
    Provider Business Practice Location Address Fax Number: 
803-799-0137
    Provider Enumeration Date: 
06/13/2011