Provider First Line Business Practice Location Address:
620 GERVAIS ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29201-3048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-779-1001
Provider Business Practice Location Address Fax Number:
803-779-1089
Provider Enumeration Date:
05/16/2007