Provider First Line Business Practice Location Address:
369 GEORGE KOSTAS DR
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25601-3493
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-962-6117
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/20/2012