Provider First Line Business Practice Location Address:
111 MCCLUNG ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
QUINWOOD
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25981-0253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-438-9252
Provider Business Practice Location Address Fax Number:
304-438-7148
Provider Enumeration Date:
06/28/2006