Provider First Line Business Practice Location Address:
437 MACCORKLE AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25303-1230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-747-2512
Provider Business Practice Location Address Fax Number:
304-747-2599
Provider Enumeration Date:
07/26/2007