Provider First Line Business Practice Location Address:
1370 JOHNSON AVE
Provider Second Line Business Practice Location Address:
STE 203
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330-1378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-622-5196
Provider Business Practice Location Address Fax Number:
304-622-2810
Provider Enumeration Date:
03/17/2006