Provider First Line Business Practice Location Address:
1115 LOGAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCMECHEN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26040-1311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-815-2059
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/24/2025