Provider First Line Business Practice Location Address:
45 PROFESSIONAL PL STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330-1788
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-623-2524
Provider Business Practice Location Address Fax Number:
304-623-0884
Provider Enumeration Date:
11/09/2006