Provider First Line Business Practice Location Address:
56 MILEGROUND RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26505-3803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-296-2273
Provider Business Practice Location Address Fax Number:
304-296-0825
Provider Enumeration Date:
09/28/2006