Provider First Line Business Practice Location Address:
5250 CLEMSON AVE
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:
29206-3042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-738-9715
Provider Business Practice Location Address Fax Number:
803-738-9717
Provider Enumeration Date:
08/27/2006