Provider First Line Business Practice Location Address:
1218 MILLER AVE
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:
29203-6417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-497-9611
Provider Business Practice Location Address Fax Number:
803-764-2003
Provider Enumeration Date:
09/19/2007