Provider First Line Business Practice Location Address:
116 W WASHINGTON ST
Provider Second Line Business Practice Location Address:
SUITE 2C
Provider Business Practice Location Address City Name:
CHARLES TOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25414-1572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-728-8282
Provider Business Practice Location Address Fax Number:
304-728-8253
Provider Enumeration Date:
07/15/2005