Provider First Line Business Practice Location Address:
118 LAFAYETTE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNDSVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26041-1029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-845-0390
Provider Business Practice Location Address Fax Number:
304-845-0391
Provider Enumeration Date:
04/16/2014