Provider First Line Business Practice Location Address:
405 12TH STREET EXT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINCETON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24740-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-425-7243
Provider Business Practice Location Address Fax Number:
304-487-3525
Provider Enumeration Date:
09/27/2006