Provider First Line Business Practice Location Address:
1422 E MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
PRINCETON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24740-3046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-425-3327
Provider Business Practice Location Address Fax Number:
304-425-4577
Provider Enumeration Date:
08/16/2005