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: 
803-733-5969
    Provider Business Practice Location Address Fax Number: 
803-748-9953
    Provider Enumeration Date: 
02/22/2006