Provider First Line Business Practice Location Address:
1900 LOCUST AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
FAIRMONT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26554-1239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-225-5222
Provider Business Practice Location Address Fax Number:
304-333-5224
Provider Enumeration Date:
06/11/2005