Provider First Line Business Practice Location Address:
1200 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE M105
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29201-3234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-983-9840
Provider Business Practice Location Address Fax Number:
800-983-9841
Provider Enumeration Date:
09/30/2010