Provider First Line Business Practice Location Address:
130 PROFESSIONAL PL
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:
26330-4599
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-933-9355
Provider Business Practice Location Address Fax Number:
304-278-3348
Provider Enumeration Date:
02/04/2009