Provider First Line Business Practice Location Address:
1825 SUMTER STREET
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:
803-771-6330
Provider Business Practice Location Address Fax Number:
803-771-6331
Provider Enumeration Date:
11/21/2006