Provider First Line Business Practice Location Address:
6TH STREET & COURT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNDSVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26041-0429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-845-7840
Provider Business Practice Location Address Fax Number:
304-843-9837
Provider Enumeration Date:
06/28/2005