Provider First Line Business Practice Location Address:
1135 CARTER STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-786-1183
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/15/2014