Provider First Line Business Practice Location Address:
1415 BLANDING STREET SUITE 2
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:
803-256-1518
Provider Business Practice Location Address Fax Number:
803-256-9719
Provider Enumeration Date:
01/31/2006