Provider First Line Business Practice Location Address:
228 UPPER RIVER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GALLIPOLIS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45631-1839
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
174-044-6383
Provider Business Practice Location Address Fax Number:
174-044-6379
Provider Enumeration Date:
03/22/2007