Provider First Line Business Practice Location Address:
3511 MEDICAL DR
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:
29203-6504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-771-0518
Provider Business Practice Location Address Fax Number:
803-771-7286
Provider Enumeration Date:
01/31/2006