Provider First Line Business Practice Location Address: 
1013 N KINGS STREET
    Provider Second Line Business Practice Location Address: 
221F
    Provider Business Practice Location Address City Name: 
COLUMBIA
    Provider Business Practice Location Address State Name: 
SC
    Provider Business Practice Location Address Postal Code: 
29223
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
803-979-9711
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/10/2022