Provider First Line Business Practice Location Address:
RR 3 BOX 9
Provider Second Line Business Practice Location Address:
439 ELIZABETH WAY
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25840-9505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-574-2600
Provider Business Practice Location Address Fax Number:
304-574-2951
Provider Enumeration Date:
03/13/2008