Provider First Line Business Practice Location Address:
ROUTE 4
Provider Second Line Business Practice Location Address:
17
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330-9804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-842-4135
Provider Business Practice Location Address Fax Number:
304-842-4398
Provider Enumeration Date:
07/27/2010