Provider First Line Business Practice Location Address: 
86 SHAE AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CHAPMANVILLE
    Provider Business Practice Location Address State Name: 
WV
    Provider Business Practice Location Address Postal Code: 
25508
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
304-855-4430
    Provider Business Practice Location Address Fax Number: 
304-855-6261
    Provider Enumeration Date: 
10/30/2014