Provider First Line Business Practice Location Address:
1812 WASHINGTON STREET
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:
29201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-254-9381
Provider Business Practice Location Address Fax Number:
803-254-1978
Provider Enumeration Date:
02/06/2007