Provider First Line Business Practice Location Address:
233 LONGTOWN 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:
29229-8550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-788-0268
Provider Business Practice Location Address Fax Number:
803-788-7384
Provider Enumeration Date:
01/25/2006