Provider First Line Business Practice Location Address: 
5122 RIPLEY RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
REEDY
    Provider Business Practice Location Address State Name: 
WV
    Provider Business Practice Location Address Postal Code: 
25270-9524
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
304-965-4594
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/27/2020