Provider First Line Business Practice Location Address:
1612 LAKE MURRAY BLVD
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:
29212-8623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-407-6511
Provider Business Practice Location Address Fax Number:
803-407-9722
Provider Enumeration Date:
03/01/2007