Provider First Line Business Practice Location Address:
1102 POPLAR STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENOVA
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-453-5458
Provider Business Practice Location Address Fax Number:
304-453-5459
Provider Enumeration Date:
10/10/2006