Provider First Line Business Practice Location Address:
1520 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 1E
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29201-5815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-988-1065
Provider Business Practice Location Address Fax Number:
803-988-1066
Provider Enumeration Date:
02/21/2011