Provider First Line Business Practice Location Address:
3039 LEAPHART RD # C
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:
29169-3050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-373-5121
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/17/2026