Provider First Line Business Practice Location Address:
529 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330-1824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-842-4202
Provider Business Practice Location Address Fax Number:
304-842-6480
Provider Enumeration Date:
05/31/2006