Provider First Line Business Practice Location Address:
5301 N TRENHOLM RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29206-3226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-787-7889
Provider Business Practice Location Address Fax Number:
803-790-9988
Provider Enumeration Date:
12/28/2006