Provider First Line Business Practice Location Address:
1160 JOHNSON AVE
Provider Second Line Business Practice Location Address:
STE 105
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-842-9084
Provider Business Practice Location Address Fax Number:
304-842-9085
Provider Enumeration Date:
11/01/2006