Provider First Line Business Practice Location Address:
234 WEST PORTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-526-9652
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/06/2012