Provider First Line Business Practice Location Address:
HC 68 BOX 1000
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25601-9620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-239-3888
Provider Business Practice Location Address Fax Number:
304-239-3811
Provider Enumeration Date:
11/21/2006