Provider First Line Business Practice Location Address: 
8 BETTY LN
    Provider Second Line Business Practice Location Address: 
STE 101
    Provider Business Practice Location Address City Name: 
SCOTT DEPOT
    Provider Business Practice Location Address State Name: 
WV
    Provider Business Practice Location Address Postal Code: 
25560-8914
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
304-201-2576
    Provider Business Practice Location Address Fax Number: 
304-201-2578
    Provider Enumeration Date: 
12/06/2007