Provider First Line Business Practice Location Address: 
2300 MACCORKLE AVE SE
    Provider Second Line Business Practice Location Address: 
RATRIE HALL BOX #70
    Provider Business Practice Location Address City Name: 
CHARLESTON
    Provider Business Practice Location Address State Name: 
WV
    Provider Business Practice Location Address Postal Code: 
25304-1045
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
954-290-1667
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/27/2014