Provider First Line Business Practice Location Address:
1445 SHOP RD STE A
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:
29201-4817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-926-0252
Provider Business Practice Location Address Fax Number:
803-926-0236
Provider Enumeration Date:
07/13/2006