Provider First Line Business Practice Location Address:
1036 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:
25601-3355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-896-2127
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2024