Provider First Line Business Practice Location Address:
24 MACCORKLE AVE SW
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
SOUTH CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25303-1476
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-720-5000
Provider Business Practice Location Address Fax Number:
304-720-5003
Provider Enumeration Date:
09/14/2005