Provider First Line Business Practice Location Address:
222 E MEDICAL LN STE 100&200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29169-4847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-935-8410
Provider Business Practice Location Address Fax Number:
803-936-7816
Provider Enumeration Date:
06/21/2012