Provider First Line Business Practice Location Address:
1441 WASHINGTON STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOLIVAR
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25425-0490
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-535-1910
Provider Business Practice Location Address Fax Number:
304-535-1943
Provider Enumeration Date:
01/23/2007