Provider First Line Business Practice Location Address:
RT 220 SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UPPER TRACT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-293-5033
Provider Business Practice Location Address Fax Number:
304-293-6963
Provider Enumeration Date:
05/23/2007