Provider First Line Business Practice Location Address:
405 FAYETTE PIKE
Provider Second Line Business Practice Location Address:
WVU TECH ATHLETIC TRAINING
Provider Business Practice Location Address City Name:
MONTGOMERY
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25136-2437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-442-3496
Provider Business Practice Location Address Fax Number:
304-442-3499
Provider Enumeration Date:
05/08/2007