Provider First Line Business Practice Location Address:
661 LICK BRANCH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25312-6761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-208-0707
Provider Business Practice Location Address Fax Number:
855-851-4405
Provider Enumeration Date:
10/28/2005