Provider First Line Business Practice Location Address:
631 S 25TH STREET
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:
47803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-232-8803
Provider Business Practice Location Address Fax Number:
812-232-1305
Provider Enumeration Date:
09/28/2007