Provider First Line Business Practice Location Address:
177 MIDDLETOWN RD STE 5
Provider Second Line Business Practice Location Address:
WHITE HALL PROFESSIONAL COMPLEX
Provider Business Practice Location Address City Name:
FAIRMONT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26554-8254
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-516-3824
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/23/2014