Provider First Line Business Practice Location Address: 
21 AUCTION LANE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BUCKHANNON
    Provider Business Practice Location Address State Name: 
WV
    Provider Business Practice Location Address Postal Code: 
26201-2236
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
304-472-6041
    Provider Business Practice Location Address Fax Number: 
304-517-8901
    Provider Enumeration Date: 
03/31/2006