Provider First Line Business Practice Location Address:
107 KOONTZ AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLENDENIN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25045-9578
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-548-7272
Provider Business Practice Location Address Fax Number:
304-548-7149
Provider Enumeration Date:
04/11/2011