Provider First Line Business Practice Location Address:
1212 JOHNSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330-1354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-842-3763
Provider Business Practice Location Address Fax Number:
304-842-7648
Provider Enumeration Date:
07/22/2006