Provider First Line Business Practice Location Address:
1649 HARRIS HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26181-9762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-863-3051
Provider Business Practice Location Address Fax Number:
304-863-8813
Provider Enumeration Date:
10/23/2006