Provider First Line Business Practice Location Address:
5399 S US HIGHWAY 41 STE 113
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:
47802-4781
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-298-8883
Provider Business Practice Location Address Fax Number:
812-298-8889
Provider Enumeration Date:
10/18/2006