Provider First Line Business Practice Location Address:
301 GEORGE KOSTAS DR
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:
25601-3493
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-752-1450
Provider Business Practice Location Address Fax Number:
304-752-4390
Provider Enumeration Date:
03/13/2007