Provider First Line Business Practice Location Address:
557 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25601-3809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-752-3435
Provider Business Practice Location Address Fax Number:
740-753-3436
Provider Enumeration Date:
10/15/2014