Provider First Line Business Practice Location Address:
3901 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:
47802-5709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-234-8261
Provider Business Practice Location Address Fax Number:
812-234-8262
Provider Enumeration Date:
08/31/2006