Provider First Line Business Practice Location Address:
1504 S CENTER 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:
47802-1603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-235-5550
Provider Business Practice Location Address Fax Number:
812-478-4165
Provider Enumeration Date:
09/26/2006