Provider First Line Business Practice Location Address:
104 MAIN ST
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:
25601-3607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-752-4950
Provider Business Practice Location Address Fax Number:
304-752-9452
Provider Enumeration Date:
08/15/2023