Provider First Line Business Practice Location Address:
1418A MACCORKLE AVE SW
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:
25303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-348-1288
Provider Business Practice Location Address Fax Number:
304-348-1262
Provider Enumeration Date:
07/24/2006