Provider First Line Business Practice Location Address:
40 12TH ST
Provider Second Line Business Practice Location Address:
SUITE 222
Provider Business Practice Location Address City Name:
WHEELING
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26003-3279
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-233-7778
Provider Business Practice Location Address Fax Number:
304-243-9653
Provider Enumeration Date:
10/15/2005