Provider First Line Business Practice Location Address:
1400 LAUREL ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29201-2500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-240-8084
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/25/2011