Provider First Line Business Practice Location Address:
40 12TH ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
WHEELING
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26003-3279
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-242-2817
Provider Business Practice Location Address Fax Number:
304-242-5161
Provider Enumeration Date:
05/26/2007