Provider First Line Business Practice Location Address: 
170 LAKEVIEW DR
    Provider Second Line Business Practice Location Address: 
SUITE 2
    Provider Business Practice Location Address City Name: 
MORGANTOWN
    Provider Business Practice Location Address State Name: 
WV
    Provider Business Practice Location Address Postal Code: 
26508-9284
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
304-594-1545
    Provider Business Practice Location Address Fax Number: 
304-594-1547
    Provider Enumeration Date: 
10/26/2011