Provider First Line Business Practice Location Address:
3000 NE MEDICAL PARK
Provider Second Line Business Practice Location Address:
SUITE 212
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29223-6251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-865-6008
Provider Business Practice Location Address Fax Number:
803-865-6018
Provider Enumeration Date:
03/22/2006