Provider First Line Business Practice Location Address:
143 1/2 STOLLINGS AVE
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:
25601-4010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-752-4926
Provider Business Practice Location Address Fax Number:
304-752-4952
Provider Enumeration Date:
10/21/2011