Provider First Line Business Practice Location Address:
120 MEDICAL PARK DR
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330-9012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-842-4000
Provider Business Practice Location Address Fax Number:
304-842-8002
Provider Enumeration Date:
10/29/2014