Provider First Line Business Practice Location Address: 
417 HOWARD ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SHINNSTON
    Provider Business Practice Location Address State Name: 
WV
    Provider Business Practice Location Address Postal Code: 
26431-1106
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
304-629-5083
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/15/2022