Provider First Line Business Practice Location Address:
2212 DEVINE 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:
29205-2402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-269-5350
Provider Business Practice Location Address Fax Number:
803-269-5350
Provider Enumeration Date:
09/15/2006