Provider First Line Business Practice Location Address:
1620 LADY ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29201-3404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-799-8466
Provider Business Practice Location Address Fax Number:
803-252-7658
Provider Enumeration Date:
11/16/2006