Provider First Line Business Practice Location Address:
1228 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:
29204-1800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-748-7002
Provider Business Practice Location Address Fax Number:
803-252-5259
Provider Enumeration Date:
07/01/2011