Provider First Line Business Practice Location Address:
3815 LAMAR 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:
29203-5739
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-313-7047
Provider Business Practice Location Address Fax Number:
864-670-8029
Provider Enumeration Date:
01/18/2021