Provider First Line Business Practice Location Address:
15 MEDICAL PARK RD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29203-8003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-255-3417
Provider Business Practice Location Address Fax Number:
803-255-3451
Provider Enumeration Date:
03/07/2006