Provider First Line Business Practice Location Address:
1592 WASHINGTON STREET EAST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-340-3595
Provider Business Practice Location Address Fax Number:
304-340-3595
Provider Enumeration Date:
04/29/2008