Provider First Line Business Practice Location Address:
219 KING 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:
29205-3127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-765-9782
Provider Business Practice Location Address Fax Number:
803-777-5433
Provider Enumeration Date:
05/13/2009