Provider First Line Business Practice Location Address: 
120 PROFESSIONAL PL RM P
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BRIDGEPORT
    Provider Business Practice Location Address State Name: 
WV
    Provider Business Practice Location Address Postal Code: 
26330-4599
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
681-456-6195
    Provider Business Practice Location Address Fax Number: 
812-853-9086
    Provider Enumeration Date: 
10/04/2022