Provider First Line Business Practice Location Address: 
639 N COALTER ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
STAUNTON
    Provider Business Practice Location Address State Name: 
VA
    Provider Business Practice Location Address Postal Code: 
24401-3404
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
540-885-8877
    Provider Business Practice Location Address Fax Number: 
540-887-8493
    Provider Enumeration Date: 
10/25/2006