Provider First Line Business Practice Location Address:
53 14TH ST
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
WHEELING
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26003-3433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-232-2140
Provider Business Practice Location Address Fax Number:
304-232-4760
Provider Enumeration Date:
07/24/2006