Provider First Line Business Practice Location Address:
4757 S 7TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47802-4559
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-234-2289
Provider Business Practice Location Address Fax Number:
812-232-4234
Provider Enumeration Date:
10/31/2005