Provider First Line Business Practice Location Address:
2301 DEVINE ST
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:
29205-2403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-233-3835
Provider Business Practice Location Address Fax Number:
888-704-7678
Provider Enumeration Date:
12/16/2005