Provider First Line Business Practice Location Address:
901 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29033-3301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-796-0616
Provider Business Practice Location Address Fax Number:
803-796-6771
Provider Enumeration Date:
11/17/2006