Provider First Line Business Practice Location Address:
215 NORTH COURT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-574-1363
Provider Business Practice Location Address Fax Number:
304-574-1363
Provider Enumeration Date:
11/16/2006