Provider First Line Business Practice Location Address:
110 MORDINGTON AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLES TOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25414-0987
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-725-9741
Provider Business Practice Location Address Fax Number:
304-267-3599
Provider Enumeration Date:
10/05/2007