Provider First Line Business Practice Location Address:
66 SCHOOL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25601-9605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-792-2087
Provider Business Practice Location Address Fax Number:
304-752-7471
Provider Enumeration Date:
11/02/2006