Provider First Line Business Practice Location Address:
1003 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNDSVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26041-1722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-843-1192
Provider Business Practice Location Address Fax Number:
304-843-1197
Provider Enumeration Date:
01/18/2007