Provider First Line Business Practice Location Address:
120 HIGHLAND CENTER DR
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29203-9127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-419-9091
Provider Business Practice Location Address Fax Number:
803-419-9199
Provider Enumeration Date:
01/28/2011