Provider First Line Business Practice Location Address:
624 FAIRMONT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRMONT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26554-5104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-366-1438
Provider Business Practice Location Address Fax Number:
304-366-7514
Provider Enumeration Date:
02/14/2007