Provider First Line Business Practice Location Address:
40 MAIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25601-3331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-896-2383
Provider Business Practice Location Address Fax Number:
304-896-2087
Provider Enumeration Date:
03/19/2026