Provider First Line Business Practice Location Address:
135 PROFESSIONAL PLACE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
681-342-3660
Provider Business Practice Location Address Fax Number:
681-342-3598
Provider Enumeration Date:
01/26/2006