Provider First Line Business Practice Location Address:
110 BALLAH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANT TOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26574-0024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
130-427-8777
Provider Business Practice Location Address Fax Number:
304-278-7787
Provider Enumeration Date:
12/11/2012