Provider First Line Business Practice Location Address:
196 DAYTON STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRAB ORCHARD
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-255-4821
Provider Business Practice Location Address Fax Number:
304-255-2410
Provider Enumeration Date:
11/08/2006