Provider First Line Business Practice Location Address:
180 MINGO AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KERMIT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25674-0248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-393-1030
Provider Business Practice Location Address Fax Number:
304-393-1026
Provider Enumeration Date:
09/23/2008