Provider First Line Business Practice Location Address:
1708 LAUREL 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:
803-252-6222
Provider Business Practice Location Address Fax Number:
803-771-7724
Provider Enumeration Date:
02/09/2006