Provider First Line Business Practice Location Address:
6830 GARNERS FERRY RD
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:
29209-1609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-729-0122
Provider Business Practice Location Address Fax Number:
866-771-6123
Provider Enumeration Date:
08/17/2011