Provider First Line Business Practice Location Address:
2101 JACOB ST. SUITE 201
Provider Second Line Business Practice Location Address:
VALLEY PROF CENTER SOUTH
Provider Business Practice Location Address City Name:
WHEELING
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26003-6390
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-242-9245
Provider Business Practice Location Address Fax Number:
304-242-6870
Provider Enumeration Date:
12/06/2006