Provider First Line Business Practice Location Address:
101 GREAT TEAYS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOTT DEPOT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25560-9550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-757-8952
Provider Business Practice Location Address Fax Number:
304-757-5460
Provider Enumeration Date:
07/10/2006