Provider First Line Business Practice Location Address:
4611 HARD SCRABBLE RD
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29229-9453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-462-6110
Provider Business Practice Location Address Fax Number:
803-462-9814
Provider Enumeration Date:
09/26/2005