Provider First Line Business Practice Location Address:
1228 HARDEN 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:
29204-1800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-733-5969
Provider Business Practice Location Address Fax Number:
803-748-9953
Provider Enumeration Date:
02/22/2006