Provider First Line Business Practice Location Address:
2211 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:
29212-0951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-407-3185
Provider Business Practice Location Address Fax Number:
803-407-3581
Provider Enumeration Date:
05/03/2007