Provider First Line Business Practice Location Address: 
23 W MAIN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LURAY
    Provider Business Practice Location Address State Name: 
VA
    Provider Business Practice Location Address Postal Code: 
22835-1230
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
540-743-4548
    Provider Business Practice Location Address Fax Number: 
540-743-6067
    Provider Enumeration Date: 
03/07/2007