Provider First Line Business Practice Location Address:
25 HOLDEN RD
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:
25601-4010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-239-2380
Provider Business Practice Location Address Fax Number:
304-239-2384
Provider Enumeration Date:
07/10/2006