Provider First Line Business Practice Location Address:
157 BACK ALLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COAL MOUNTAIN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24823-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-640-8726
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/10/2024