Provider First Line Business Practice Location Address:
117 WEST WAGNER STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLENBORO
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26346
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-869-3888
Provider Business Practice Location Address Fax Number:
304-869-3888
Provider Enumeration Date:
08/14/2006