Provider First Line Business Practice Location Address:
132 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330-1715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-842-9229
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/27/2005