Provider First Line Business Practice Location Address:
2589 FAIRMONT AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
FAIRMONT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26554-3442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-333-6668
Provider Business Practice Location Address Fax Number:
304-333-6666
Provider Enumeration Date:
09/19/2005