Provider First Line Business Practice Location Address:
1700 HENDERSON 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:
29201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-779-2633
Provider Business Practice Location Address Fax Number:
803-779-2699
Provider Enumeration Date:
03/06/2007