Provider First Line Business Practice Location Address:
141 WATER STREET DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOOREFIELD
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26836-1058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-538-2559
Provider Business Practice Location Address Fax Number:
304-538-6421
Provider Enumeration Date:
07/27/2005