Provider First Line Business Practice Location Address:
850 INDEPENDENCE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COAL CITY
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25823-1595
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-469-2905
Provider Business Practice Location Address Fax Number:
304-683-6906
Provider Enumeration Date:
10/20/2006