Provider First Line Business Practice Location Address:
314 SCOTT AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-291-2912
Provider Business Practice Location Address Fax Number:
304-291-2912
Provider Enumeration Date:
10/31/2006