Provider First Line Business Practice Location Address:
4530 5TH STREET RD
Provider Second Line Business Practice Location Address:
UNIT B
Provider Business Practice Location Address City Name:
HUNTINGTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25701-9564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-525-4782
Provider Business Practice Location Address Fax Number:
304-525-4782
Provider Enumeration Date:
04/08/2010