Provider First Line Business Practice Location Address:
154 W MAIN ST
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330-1715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-842-0601
Provider Business Practice Location Address Fax Number:
304-842-0602
Provider Enumeration Date:
08/05/2006