Provider First Line Business Practice Location Address:
3000 NE MEDICAL PARK
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29223-6251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-462-9200
Provider Business Practice Location Address Fax Number:
803-699-1474
Provider Enumeration Date:
06/24/2005