Provider First Line Business Practice Location Address: 
1718 WONDERLAND RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FAYETTEVILLE
    Provider Business Practice Location Address State Name: 
WV
    Provider Business Practice Location Address Postal Code: 
25840-5248
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
304-543-8289
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/06/2006