Provider First Line Business Practice Location Address: 
6186 BIRKEWOOD RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HUNTINGTON
    Provider Business Practice Location Address State Name: 
WV
    Provider Business Practice Location Address Postal Code: 
25705-2202
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
304-736-6264
    Provider Business Practice Location Address Fax Number: 
304-736-4852
    Provider Enumeration Date: 
12/01/2006