Provider First Line Business Practice Location Address:
4012 TEAYS VALLEY RD
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:
25560-9760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-201-1630
Provider Business Practice Location Address Fax Number:
304-201-1635
Provider Enumeration Date:
09/19/2012