Provider First Line Business Practice Location Address:
SUSSEX II STATE PRISON
Provider Second Line Business Practice Location Address:
24427 MUSSELWHITE DR
Provider Business Practice Location Address City Name:
WAVERLY
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23891-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-834-2678
Provider Business Practice Location Address Fax Number:
804-834-2600
Provider Enumeration Date:
04/23/2007