Provider First Line Business Practice Location Address:
3415 MACCORKLE AVE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-388-1790
Provider Business Practice Location Address Fax Number:
304-388-1768
Provider Enumeration Date:
07/12/2005