Provider First Line Business Practice Location Address:
3685 LEAPHART RD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29169-3067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-454-0194
Provider Business Practice Location Address Fax Number:
803-451-7128
Provider Enumeration Date:
06/10/2006