Provider First Line Business Practice Location Address:
1001 W BALTIMORE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCMECHEN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26040-1503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-242-4004
Provider Business Practice Location Address Fax Number:
304-242-8004
Provider Enumeration Date:
08/22/2007