Provider First Line Business Practice Location Address:
1228 HARDEN ST STE C
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:
29204-1800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-748-1184
Provider Business Practice Location Address Fax Number:
803-748-1185
Provider Enumeration Date:
09/14/2006