Provider First Line Business Practice Location Address:
69 MAIN STREET
Provider Second Line Business Practice Location Address:
3RD
Provider Business Practice Location Address City Name:
NORTHFORK
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24868-0085
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-962-3144
Provider Business Practice Location Address Fax Number:
304-862-3071
Provider Enumeration Date:
02/25/2008