Provider First Line Business Practice Location Address:
1216 LAFAYETTE AVE
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:
26041-2315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-693-2781
Provider Business Practice Location Address Fax Number:
304-693-2171
Provider Enumeration Date:
08/22/2017