Provider First Line Business Practice Location Address:
640 FAIRFAX ST
Provider Second Line Business Practice Location Address:
SUITE #3
Provider Business Practice Location Address City Name:
BERKELEY SPRINGS
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25411-1622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-258-5353
Provider Business Practice Location Address Fax Number:
304-258-9313
Provider Enumeration Date:
11/01/2006