Provider First Line Business Practice Location Address:
MAIN STREET
Provider Second Line Business Practice Location Address:
CHAPMANVILLE PROG BLDG SUITE #7
Provider Business Practice Location Address City Name:
CHAMPMANVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25508-4541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-855-3939
Provider Business Practice Location Address Fax Number:
304-855-5939
Provider Enumeration Date:
11/01/2006