Provider First Line Business Practice Location Address:
4621 HARDSCRABBLE RD
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:
29229-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-736-8955
Provider Business Practice Location Address Fax Number:
803-699-8049
Provider Enumeration Date:
02/12/2013