Provider First Line Business Practice Location Address: 
870 BLOODY RUN RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MORGANTOWN
    Provider Business Practice Location Address State Name: 
WV
    Provider Business Practice Location Address Postal Code: 
26508-4794
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
304-291-5263
    Provider Business Practice Location Address Fax Number: 
304-296-5989
    Provider Enumeration Date: 
11/20/2006