Provider First Line Business Practice Location Address:
7001 ST ANDREWS RD
Provider Second Line Business Practice Location Address:
A-16
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-749-9988
Provider Business Practice Location Address Fax Number:
803-749-9096
Provider Enumeration Date:
10/12/2006