Provider First Line Business Practice Location Address:
132 N LAFAYETTE AVENUE
Provider Second Line Business Practice Location Address:
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:
304-845-9550
Provider Business Practice Location Address Fax Number:
304-845-9540
Provider Enumeration Date:
11/20/2006