Provider First Line Business Practice Location Address:
222 E MEDICAL LN STE 101
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:
29169-4847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-739-3660
Provider Business Practice Location Address Fax Number:
803-739-3663
Provider Enumeration Date:
07/10/2006