Provider First Line Business Practice Location Address:
19 JIMS BRANCH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25121-7106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-601-5508
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/04/2025