Provider First Line Business Practice Location Address: 
118 NICK SAVAS DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LOGAN
    Provider Business Practice Location Address State Name: 
WV
    Provider Business Practice Location Address Postal Code: 
25601-3468
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
304-752-4045
    Provider Business Practice Location Address Fax Number: 
304-752-4045
    Provider Enumeration Date: 
08/08/2006