Provider First Line Business Practice Location Address:
605 CAPITOL PLACE
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-926-2607
Provider Business Practice Location Address Fax Number:
803-799-7652
Provider Enumeration Date:
08/01/2006