Provider First Line Business Practice Location Address:
200 ROUTE 98 MEDWOOD PLAZA
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
NUTTER FORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-622-5711
Provider Business Practice Location Address Fax Number:
304-622-6001
Provider Enumeration Date:
06/21/2012