Provider First Line Business Practice Location Address:
3595 HARDEN ST EXT
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:
29203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-799-1217
Provider Business Practice Location Address Fax Number:
803-799-8095
Provider Enumeration Date:
09/11/2012