Provider First Line Business Practice Location Address:
1513 PICKENS ST
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:
29201-3448
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-765-9944
Provider Business Practice Location Address Fax Number:
803-799-6267
Provider Enumeration Date:
12/21/2007