Provider First Line Business Practice Location Address:
306 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330-1751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-842-3137
Provider Business Practice Location Address Fax Number:
304-842-3138
Provider Enumeration Date:
06/28/2005