Provider First Line Business Practice Location Address: 
401 SOUTH QUEEN STREET
    Provider Second Line Business Practice Location Address: 
BERKELEY COUNTY BOARD OF EDUCATION
    Provider Business Practice Location Address City Name: 
MARTINSBURG
    Provider Business Practice Location Address State Name: 
WV
    Provider Business Practice Location Address Postal Code: 
25401
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
304-267-3595
    Provider Business Practice Location Address Fax Number: 
304-267-3599
    Provider Enumeration Date: 
10/22/2014