Provider First Line Business Practice Location Address: 
212 N COURT ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WAYNE
    Provider Business Practice Location Address State Name: 
WV
    Provider Business Practice Location Address Postal Code: 
25570
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
304-272-5116
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/13/2007