Provider First Line Business Practice Location Address:
RT 14 NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZABETH
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-275-4687
Provider Business Practice Location Address Fax Number:
304-275-4502
Provider Enumeration Date:
12/18/2009