Provider First Line Business Practice Location Address:
1330 GREGG 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-254-1911
Provider Business Practice Location Address Fax Number:
803-254-7120
Provider Enumeration Date:
11/28/2006