Provider First Line Business Practice Location Address:
149 JERRY WEST HWY
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25601-3955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-752-2800
Provider Business Practice Location Address Fax Number:
304-752-2111
Provider Enumeration Date:
09/08/2006