Provider First Line Business Practice Location Address:
816 MAIN STREET, SUITE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAPMANVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-853-5554
Provider Business Practice Location Address Fax Number:
304-853-5504
Provider Enumeration Date:
06/28/2007