Provider First Line Business Practice Location Address: 
2596 BATTLE RUN RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
TRIADELPHIA
    Provider Business Practice Location Address State Name: 
WV
    Provider Business Practice Location Address Postal Code: 
26059-1200
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
304-547-2928
    Provider Business Practice Location Address Fax Number: 
304-547-2929
    Provider Enumeration Date: 
08/20/2009