Provider First Line Business Practice Location Address:
5500 WABASH AVE
Provider Second Line Business Practice Location Address:
CM 41
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47803-3920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-877-8554
Provider Business Practice Location Address Fax Number:
812-872-6051
Provider Enumeration Date:
03/14/2006