Provider First Line Business Practice Location Address:
725 S MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42261-9431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-526-6206
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/11/2011