Provider First Line Business Practice Location Address:
1370 JOHNSON AVE
Provider Second Line Business Practice Location Address:
1ST FLOOR
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-842-3330
Provider Business Practice Location Address Fax Number:
304-842-3303
Provider Enumeration Date:
12/20/2006