Provider First Line Business Practice Location Address:
RR 1 BOX 217A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNDSVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26041-9725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-845-2303
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/13/2005