Provider First Line Business Practice Location Address:
3214 LEAPHART RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
WEST COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29169-3005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-739-4442
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/14/2010