Provider First Line Business Practice Location Address:
3000 NE MEDICAL PARK
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29223-6253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-736-4845
Provider Business Practice Location Address Fax Number:
803-736-8674
Provider Enumeration Date:
01/18/2007