Provider First Line Business Practice Location Address:
126 CARPENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHADY SPRING
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25918-8417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-255-2426
Provider Business Practice Location Address Fax Number:
304-253-3715
Provider Enumeration Date:
09/27/2005