Provider First Line Business Practice Location Address:
114 W WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLES TOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25414-1543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-725-2621
Provider Business Practice Location Address Fax Number:
304-728-4321
Provider Enumeration Date:
12/28/2005