Provider First Line Business Practice Location Address:
17978 STATE ROUTE 55
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAKER
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26801-0031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-897-8220
Provider Business Practice Location Address Fax Number:
304-897-8210
Provider Enumeration Date:
01/26/2010