Provider First Line Business Practice Location Address:
264 COAL RIVER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLEN DANIEL
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25844-9402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-934-5125
Provider Business Practice Location Address Fax Number:
304-934-6967
Provider Enumeration Date:
02/28/2007