Provider First Line Business Practice Location Address: 
2413 E PIKE ST STE 121
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CLARKSBURG
    Provider Business Practice Location Address State Name: 
WV
    Provider Business Practice Location Address Postal Code: 
26301-9117
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
304-669-7975
    Provider Business Practice Location Address Fax Number: 
304-566-7533
    Provider Enumeration Date: 
01/20/2018