Provider First Line Business Practice Location Address:
4424 S 7TH 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:
47801-0218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-299-3937
Provider Business Practice Location Address Fax Number:
812-299-8670
Provider Enumeration Date:
05/17/2006