Provider First Line Business Practice Location Address:
2 MEDICAL PARK RD STE LL9
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:
29203-6875
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-344-9660
Provider Business Practice Location Address Fax Number:
803-434-9669
Provider Enumeration Date:
06/16/2005