Provider First Line Business Practice Location Address:
234 WEST PORTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42261-8629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-526-9652
Provider Business Practice Location Address Fax Number:
270-526-9655
Provider Enumeration Date:
10/04/2006