Provider First Line Business Practice Location Address:
1332 PICKENS 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:
29201-3430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-771-4160
Provider Business Practice Location Address Fax Number:
803-771-4367
Provider Enumeration Date:
09/18/2013