Provider First Line Business Practice Location Address:
4500 12TH STREET EXT
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:
29172-3025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-462-5005
Provider Business Practice Location Address Fax Number:
803-926-0674
Provider Enumeration Date:
02/17/2020