Provider First Line Business Practice Location Address:
1411 BARNWELL 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:
29201-3566
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-451-1104
Provider Business Practice Location Address Fax Number:
803-799-9458
Provider Enumeration Date:
07/11/2012