Provider First Line Business Practice Location Address:
396 DINGESS 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:
25601-3624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-831-1700
Provider Business Practice Location Address Fax Number:
304-831-1726
Provider Enumeration Date:
04/17/2006