Provider First Line Business Practice Location Address:
ROUTE 16 BOX 149
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW RICHMOND
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24867-0149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-294-7584
Provider Business Practice Location Address Fax Number:
304-294-8761
Provider Enumeration Date:
12/28/2006