Provider First Line Business Practice Location Address:
1749 MARSHALL 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:
29203-6952
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-252-1816
Provider Business Practice Location Address Fax Number:
803-252-9132
Provider Enumeration Date:
11/18/2005