Provider First Line Business Practice Location Address: 
29 ASH LN
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ELKINS
    Provider Business Practice Location Address State Name: 
WV
    Provider Business Practice Location Address Postal Code: 
26241-1112
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
304-614-9222
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/19/2021