Provider First Line Business Practice Location Address:
2800 POPLAR STREET
Provider Second Line Business Practice Location Address:
STE 19 A
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47803-2659
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-235-7252
Provider Business Practice Location Address Fax Number:
812-235-7176
Provider Enumeration Date:
06/30/2005