Provider First Line Business Practice Location Address:
114 HUMPHREYS TRAILER PARK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALLARD
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24918-8106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-961-6663
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/15/2026