Provider First Line Business Practice Location Address:
79 GROVER SMITH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAKER
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26801-0058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-897-6028
Provider Business Practice Location Address Fax Number:
304-897-7010
Provider Enumeration Date:
02/02/2007