Provider First Line Business Practice Location Address:
215 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330-1748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-842-6645
Provider Business Practice Location Address Fax Number:
304-842-4909
Provider Enumeration Date:
09/16/2005