Provider First Line Business Practice Location Address:
1400 JOHNSON AVE
Provider Second Line Business Practice Location Address:
SUITE 4H
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330-1063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-842-1990
Provider Business Practice Location Address Fax Number:
304-842-4471
Provider Enumeration Date:
07/07/2005