Provider First Line Business Practice Location Address:
527 MEDICAL PARK DR
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330-9009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-933-3855
Provider Business Practice Location Address Fax Number:
304-933-3859
Provider Enumeration Date:
05/28/2006