Provider First Line Business Practice Location Address: 
1417 GREGG 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: 
29201-3527
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
803-758-2445
    Provider Business Practice Location Address Fax Number: 
803-758-2445
    Provider Enumeration Date: 
12/09/2013