Provider First Line Business Practice Location Address:
5499 OLD LOGAN RD
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:
25601-3072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-627-4711
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/02/2023