Provider First Line Business Practice Location Address:
1113 2ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST LOGAN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25601-3309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-752-1900
Provider Business Practice Location Address Fax Number:
304-752-0188
Provider Enumeration Date:
03/05/2022