Provider First Line Business Practice Location Address:
112 BRIDGE ST
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:
25601-3602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-896-5025
Provider Business Practice Location Address Fax Number:
304-896-5058
Provider Enumeration Date:
06/21/2017