Provider First Line Business Practice Location Address:
529 RICHLAND 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:
29201-2320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-748-8797
Provider Business Practice Location Address Fax Number:
803-748-8799
Provider Enumeration Date:
03/05/2007