Provider First Line Business Practice Location Address:
1205 PENDLETON ST
Provider Second Line Business Practice Location Address:
SUITE 372 BROWN BUILDING
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29201-3756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-734-4525
Provider Business Practice Location Address Fax Number:
803-734-4538
Provider Enumeration Date:
10/26/2012