Provider First Line Business Practice Location Address:
80 12TH STREET
Provider Second Line Business Practice Location Address:
SUITE 307 BOARD OF TRADE BUILDING
Provider Business Practice Location Address City Name:
WHEELING
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-242-6988
Provider Business Practice Location Address Fax Number:
304-242-6951
Provider Enumeration Date:
05/24/2006