Provider First Line Business Practice Location Address:
300 STRATTON ST
Provider Second Line Business Practice Location Address:
ROOM 203
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25601-3924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-792-8630
Provider Business Practice Location Address Fax Number:
304-792-8635
Provider Enumeration Date:
08/13/2008