Provider First Line Business Practice Location Address:
2012 HARDEN ST STE 112
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:
29204-0915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-231-3122
Provider Business Practice Location Address Fax Number:
803-231-3116
Provider Enumeration Date:
07/20/2012