Provider First Line Business Practice Location Address:
917 W MAIN ST
Provider Second Line Business Practice Location Address:
HARRON SQUARE, SUITE 203
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330-1650
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-842-7007
Provider Business Practice Location Address Fax Number:
304-842-7099
Provider Enumeration Date:
01/25/2006