Provider First Line Business Practice Location Address: 
407 3RD AVE E
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BIG STONE GAP
    Provider Business Practice Location Address State Name: 
VA
    Provider Business Practice Location Address Postal Code: 
24219-2365
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
276-523-0931
    Provider Business Practice Location Address Fax Number: 
276-523-0932
    Provider Enumeration Date: 
05/24/2005