Provider First Line Business Practice Location Address:
4214 HARD SCRABBLE RD
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:
29223-8560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-736-8955
Provider Business Practice Location Address Fax Number:
803-699-8049
Provider Enumeration Date:
10/06/2006