Provider First Line Business Practice Location Address:
1730 HENDERSON STREET
Provider Second Line Business Practice Location Address:
SUITE B
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:
803-376-1717
Provider Business Practice Location Address Fax Number:
803-376-1716
Provider Enumeration Date:
05/18/2006