Provider First Line Business Practice Location Address:
131 DANIELS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25840-1215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-574-2950
Provider Business Practice Location Address Fax Number:
304-574-2958
Provider Enumeration Date:
06/28/2007