Provider First Line Business Practice Location Address:
2365 RT. 21 SOUTH
Provider Second Line Business Practice Location Address:
FAIRHAVEN SQUARE SUITE J
Provider Business Practice Location Address City Name:
RIPLEY
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25271
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-372-7500
Provider Business Practice Location Address Fax Number:
304-372-4332
Provider Enumeration Date:
07/09/2006