Provider First Line Business Practice Location Address: 
916 W MAIN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BRIDGEPORT
    Provider Business Practice Location Address State Name: 
WV
    Provider Business Practice Location Address Postal Code: 
26330-1651
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
304-842-1034
    Provider Business Practice Location Address Fax Number: 
304-842-1037
    Provider Enumeration Date: 
09/13/2010