Provider First Line Business Practice Location Address:
417 MUD FORK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25601-1719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-855-4011
Provider Business Practice Location Address Fax Number:
304-855-7028
Provider Enumeration Date:
07/15/2005