Provider First Line Business Practice Location Address:
2123 BROAD RIVER ROAD
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:
29210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-798-2377
Provider Business Practice Location Address Fax Number:
803-798-4292
Provider Enumeration Date:
08/30/2006