Provider First Line Business Practice Location Address:
143 PEYTON STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARBOURSVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-697-2035
Provider Business Practice Location Address Fax Number:
304-781-2647
Provider Enumeration Date:
09/13/2005