Provider First Line Business Practice Location Address:
114 BARNWELL
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:
29201-1627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-665-8164
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/30/2006