Provider First Line Business Practice Location Address:
RR 5 BOX 697
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARKSBURG
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26301-9300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-624-9875
Provider Business Practice Location Address Fax Number:
304-624-8971
Provider Enumeration Date:
03/13/2007