Provider First Line Business Practice Location Address:
1825 SUMTER 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:
29201-2501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-858-3873
Provider Business Practice Location Address Fax Number:
704-547-0887
Provider Enumeration Date:
04/13/2011