Provider First Line Business Practice Location Address:
112 CORRECTIONAL DR.
Provider Second Line Business Practice Location Address:
NORTHERN REGIONAL CORRECTIONAL FACILITY
Provider Business Practice Location Address City Name:
MOUNDSVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-843-4084
Provider Business Practice Location Address Fax Number:
304-843-4089
Provider Enumeration Date:
04/04/2017