Provider First Line Business Practice Location Address:
2415 JACKSON AVE
Provider Second Line Business Practice Location Address:
1B
Provider Business Practice Location Address City Name:
POINT PLEASANT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25550-2042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-812-5931
Provider Business Practice Location Address Fax Number:
304-812-5933
Provider Enumeration Date:
12/31/2012