Provider First Line Business Practice Location Address:
211 W MAPLE AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25840-1445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-900-5511
Provider Business Practice Location Address Fax Number:
304-900-5558
Provider Enumeration Date:
09/29/2005