Provider First Line Business Practice Location Address:
65 PROFESSIONAL PLACE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-842-6463
Provider Business Practice Location Address Fax Number:
304-842-8180
Provider Enumeration Date:
06/12/2012