Provider First Line Business Practice Location Address:
305 FAYETTE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26505-5652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-292-6212
Provider Business Practice Location Address Fax Number:
304-296-9562
Provider Enumeration Date:
03/13/2007